Mosby's Guide to Physical Examination, 7th Edition

CHAPTER 20. The Healthy Female Evaluation

Following are items to consider for inclusion as part of a routine well-woman visit. This is not intended as an all-inclusive list. Some items may vary depending on the woman’s age, health status, and particular risk factors. Past medical history (PMH) and review of systems (ROS) may also be appropriate if indicated. Age and risk-status guidelines for preventive services are available from a variety of sources and authorities.*

HISTORY

HISTORY OF PRESENT ILLNESS (HPI)

Age

Last normal menstrual period (LNMP)

Menopause—age achieved, symptoms

Obstetric history—number of pregnancies, term pregnancies, preterm pregnancies, abortions/miscarriages, living children (GTPAL)

Contraceptive measures and history

Sexual history

Breast lumps, discharge, pain, skin changes

Unusual vaginal bleeding or discharge

Abdominal or pelvic pain or bloating

Urinary symptoms

RISK ASSESSMENT

Cardiovascular—smoking, hypertension, diet, body mass index (BMI), exercise, family history

Cancer—personal/family history of breast, ovarian, or colon cancer; history of sun exposure

Infection—sexually transmitted infection (STI) exposure; tuberculosis exposure; hepatitis vaccine or exposure; tetanus/flu immunization

Metabolic—calcium supplement, family/personal history of osteoporosis; exercise; personal/family history of diabetes mellitus; hearing impairment in older adults

Injury—alcohol, seat belts, guns, family violence

Mental health—depression: vegetative symptoms (eating, sleeping, concentration, energy, social interaction)

HEALTH HABITS

Breast self-awareness or self-examination

Pap smear—how often; date of last Pap smear; results, ever an abnormal result?

HPV DNA test—date, results

Mammogram—date, result of last mammogram

Diet—fat, cholesterol, calcium

Exercise—amount, frequency

Smoking/tobacco use

Alcohol/drugs

PHYSICAL EXAMINATION

Vital signs: BP

Height and weight; BMI

Skin—lesions, moles

Lungs

Cardiovascular and peripheral vascular

Breasts—contour, masses, nipple discharge, skin changes

Lymph—regional lymphadenopathy (infraclavicular and supraclavicular, axillary, inguinal)

Abdomen—bowel sounds, masses, organ enlargement, hernias

Pelvic—lesions, discharge; Bartholin glands, urethra, Skene glands; vagina, cervix, adnexa, uterus; rectovaginal septum

Rectal—hemorrhoids, masses, lesions

SCREENING RECOMMENDATIONS

Cardiovascular

Blood pressure—begin at age 18

Lipid profile—begin at age 45

Cancer

Pap smear—begin within 3 years of onset sexual activity or age 21 (whichever comes first) and screening at least every 3 years; frequency depends on age, sexual status, PMH, Pap smear history

HPV DNA test—women older than age 30 years, every 3 years; or if Pap smear shows ASC-US (atypical squamous cell of undetermined significance) in women older than age 20

Mammogram—begin at age 40; earlier if at increased risk; frequency depends on personal and family history, past results

Multiple fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year; or flexible sigmoidoscopy or CT colonography (virtual colonoscopy) every 5 years; or colonoscopy every 10 years—begin at age 50; earlier depending on personal and family history

Infection

STI testing—depending on exposure status; chlamydia screening—age 24 years and younger or age 25 years and older at increased risk

TB skin testing—depending on risk status

Metabolic

BMI for obesity

Fasting plasma glucose—for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg

Bone density—women ages 65 or older; begin at age 60 if at increased risk

Hearing impairment—older adults

Injury

Family violence (see Appendix Special Histories)

Mental health

Alcohol and substance abuse (see Appendix Special Histories)

Depression

* Authorities that produce prevention guidelines include Academy of Family Physicians, American Cancer Society, American College of Obstetricians and Gynecologists, American College of Physicians, American Geriatrics Society, Canadian Task Force on the Periodic Health Examination, National Cancer Institute, and the U.S. Preventive Services Task Force.