The annual well-woman visit is crucial for preventive healthcare, disease prevention, and health screening. During the visit, the provider addresses current concerns, assesses disease risks, and provides examinations or tests based on the patient's age and risks. This should include lifestyle counseling, screening, and immunizations. The physical examination involves inspection of the head, neck, chest, heart, lungs, abdomen, genitalia, and rectum. Screening recommendations include breast exams, Pap smears, STI testing, and cancer screening based on age. Common gynecologic infections addressed include bacterial vaginosis, candidiasis, trichomoniasis, gonorrhea, chlamydia, and other infections.

1. History, Physical Examination
and Preventive Health Care
JEEZREEL M. ORQUINA, RN, LPT

2. The annual well-woman visit is crucial part of general medical
care. During this visit, the healthcare provider can attend to current
gynecologic concerns, promote disease prevention, assess risks for
potential disease, and provide the indicated physical examination or
tests. This annual health encounter should include healthy lifestyle
counseling, as well as screening and immunizations as appropriate,
based on the patient’s age and risks.

3. Direct Observation
Four qualities in caring communication skills: comfort, acceptance, responsiveness, and empathy.
Components of Effective Nurse Communication
1. Be culturally sensitive
2. Establish rapport
3. Listen and respond to the woman’s concerns (empathy)
4. Be nonjudgmental
5. Include both verbal and nonverbal communication
6. Engage the woman in discussion and treatment options (partnership)
7. Convey comfort in discussing sensitive topics
8. Abandon stereotypes
9. Check for understanding of your explanations
10. Show support by helping the woman to overcome barriers to care and compliance with treatment

4. History Outline
I. Observation
II. Chief Complaint
III. History of Gynecologic
Problem(s)
IV.Significant health problems
V.Medications, habits and
allergies
VI.Family history
VII.Occupational and
avocational history
VIII.Social history
IX. Review of systems
X. Physical abuse

5. Examination, Screening, and Immunization Recommendation
for the Annual Health Maintenance Visit
AGE (Years)
19-39 40-64 65+
Vital Signs Ht, Wt, BMI, BP Ht, Wt, BMI, BP Ht, Wt, BMI, BP
Neck Adenopathy, thyroid Adenopathy, thyroid Adenopathy, thyroid
Clinical
Breast Exam
Every 3 years, beginning at
20yo
Yearly Yearly
Abdomen Yearly Yearly Yearly
Pelvic/ speculum 21+ periodically* Annually/ periodically* Annually/ periodically*
Additional Exams As indicated As indicated As indicated
Pap Smear 21+, every 3 years Every 5 with co-test (preferred)
or every 3 Pap Smears
Discontinue if negative
adequate screening and no hx
of CIN2+

6. Examination, Screening, and Immunization Recommendation
for the Annual Health Maintenance Visit
AGE (Years)
19-39 40-64 65+
Chlamydia/ Gonorrhea <26 and sexually active, yearly As indicated As indicated
Colon cancer screening n/a 50+, colonoscopy every 10 years Colonoscopy every 10 years
Diabetes testing As indicated 45+, every 3 years Every 3 years
Mammogram If indicated Yearly Yearly
Lipids If indicated 45+, every 5 years every 5 years
Thyroid-stimulating
hormone
If indicated 50+, every 5 years Every 5 years
Bone mineral density If indicated Every 2+ years
Immunizations HPV, Tdap once, TD every 10 years,
influenza yearly
Tdap once, TD every 10 years; influenza
yearly; herpes zoster once (>59)
Influenza yearly, Tdap once, TD every 10
years, pneumococcus once
HIV Offered routinely Offered routinely Offered routinely

7. Breast Examination

8. Pelvic Examination
A. Inspection
1. The vulva and introitus should be carefully inspected beginning with
the mons pubis.
2. The quality and pattern of the hair on the mons and the labia
majora should be noted. During the inspection of the pubic hair, the
nurse should look for evidence of body lice (pediculosis).

9. Pelvic Examination
A. Inspection
3. The skin of the vulva/ perineum is inspected for erythema,
excoriation, discoloration, or loss of pigment and for the presence
of vesicles, ulcerations, pustules, warty growths, or neoplastic
growths.
4. The clitoris should be noted and its size and shape described.
(Normally, it is 1 to 1.5cm in length).

10. Pelvic Examination
A. Inspection
5. Any abnormalities of the labia majora and minora should be
noted and carefully described.
6. The introitus should be observed closely. Whether the
hymen is intact, imperforate, or open and whether the
perineum gape or remains closed in the usual lithotomy
position should be noted.

11. Pelvic Examination
B. Palpation
1. The labia minora are gently separated, and the urethra is inspected
and the length of the urethra is palpated and “milked” with the
middle finger. In this way, irregularities and inflammation of Skene
glands (periurethral glands), expressed pus or mucus, or a
suburethral diverticulum can be noted,
2. The area of the posterior third of the labia majora is palpated by
placing the finger inside the introitus and the thumb on the outside
of the labium. In this way, enlargements or cysts of Bartholin glands
are noted.

12. Pelvic Examination
B. Palpation
3. The opening of the vagina should be inspected. The presence of a
cystocele or a cystourethrocele should be noted. The presence of this
abnormality may be noted either by simply observing or by asking the
patient to bear down. Likewise, the posterior wall should be observed for
a bulging upward, which would represent a rectocele. A cystic bulge in
the cul-de-sac may represent an enterocele.
4. With the patient bearing down, the cervix may become visible, indicating
prolapse of the uterus.

13. Speculum Examination
The vaginal canal is inspected during
the insertion of the speculum and upon
its removal. The vaginal epithelium
should be noted for evidence of
erythema or lesions. Vaginal lesions,
such as areas of adenosis, clear cystic
structures (Gartner cysts) or inclusion
cysts on the lines of scars or episiotomy
incisions, should be noted.

14. Papanicolaou Smear

15. Bimanual Examination

16. Rectovaginal Examination

17. GENITAL TRACT INFECTIONS

18. Infections of Bartholin Glands

19. Pediculosis Pubis

20. Scabies

21. Molluscum Contagiosum

22. Genital Herpes

23. Granuloma Inguinale (Donovanosis)

24. Lymphogranuloma Venereum

25. Chancroid

26. Syphilis
A. Primary Syphilis
B. Secondary Syphilis
C. Late or Tertiary Syphilis

27. Typical Features of Vaginitis
Bacterial Vaginosis Candidiasis Trichomoniasis
Signs and
Symptoms
Increased discharge (white, thin),
increased odor
Increased discharge (white, thick),
dysuria, pruritus, burning
Increased discharge (yellow, frothy),
increased odor, dysuria, pruritus
Discharge Thin, whitish gray, homogenous
discharge, cocci, sometimes frothy
Thick, curdy discharge, vaginal
erythema
Yellow, frothy discharge, with or without
vaginal or cervical erythema
pH >4.5 <4.5 >4.5
Wet Mount Clue cells (>20%) shift in flora, amine
odor after adding potassium
hydroxide to wet mount
Hyphae or spores Motile trichomonads, increased white cells
Treatment Metronidazole 500mg PO, bid for 7
days;
Clindamycin 300mg PO, bid for 7
days
Clotrimazole 100mg 2 vaginal tablets/
day for 3 days; Miconazole 100mg
vaginal suppository/day for 7 days;
Fluconazole 150mg 2 tablets PO, 72
hours apart; Metronidazole 500mg bid
PO for 7 days
Nitroimidazoles:
Single dose Metronidazole 2g PO.
Topical therapy for Trichomonas vaginitis is
not recommended because it does not
eliminate disease reservoirs in Bartholin and
Skene glands.

28. Gonorrhea

29. Chlamydia

30. Treatment for Pathogenic Cervical Bacteria
Gonorrhea Chlamydia
Ceftriaxone, 250mg IM, single dose
or if not an option
Cefixime, 400mg PO, single dose
plus
Azithromycin 1g orally in single doses
Azithromycin 1g PO, single dose
or
Doxycycline, 100mg PO bid for 7 days
Alternative Treatment
Erythromycin base, 500mg PO qid for 7
days, or
Ofloxacin, 300mg PO bid for 7 days, or
Levofloxacin, 500mg PO OD for 7 days