Lab Female Genitourinary System PDF

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CHAPTER 26

Female Genitourinary System

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REGIONAL WRITE-UP—FEMALE GENITOURINARY SYSTEM Date ______________________ Examiner __________________ Patient ___________________________________________________ Age _______________________ Reason for visit _______________________________________________________________________ I. Health History No Yes, explain 1. Date of last menstrual period? Age at first period? Usual cycle? Duration? Usual amount of flow? Any pain or cramps with period? 2. Ever been pregnant? How many times? Describe pregnancy(ies). Any complications? 3. Periods slowed down or stopped? 4. How often has gynecologic checkup? Date of last Pap test? Results? 5. Any problems with urinating? 6. Any unusual vaginal discharge? 7. Sores or lesions in genitals? 8. In a relationship now involving intercourse? 9. Use a contraceptive? Which one? 10. Any contact with partner who has a sexually transmitted infection? 11. Any precautions to reduce risk for STIs? 12. Taking any medications? Any hormone therapy? II. Physical Examination A. Inspect external genitalia. Skin color and mucous membranes __________________________________________________ Hair distribution ___________________________ Structures symmetric? ___________________ Clitoris _________________________________ Labia __________________________________ Urethral opening __________________________ Vaginal opening ________________________ Perineum _______________________________________________________________________ Any lesions? _____________________________________________________________________

Jarvis, Carolyn: PHYSICAL EXAMINATION AND HEALTH ASSESSMENT: Seventh Edition, Laboratory Manual. Copyright © 2016, 2012, 2008, 2004, 2000, 1996 by Saunders, an imprint of Elsevier Inc. All rights reserved.

250

UNIT III

Physical Examination

B. Palpate external genitalia. Skene glands _____________________________ Bartholin glands ________________________ Perineum _______________________________________________________________________ Assess for vaginal wall bulging or urinary incontinence. __________________________________ Discharge, color, odor, consistency ___________________________________________________ C. Speculum examination Inspect cervix and os. Color _____________________________________ Position __________________________ Size ____________________ ______________Surface ________________________________ Discharge, color, odor, consistency ________________________________________________ Nabothian cysts? ________________________ IUD string, if present ___________________ Obtain cervical smears and cultures. Vaginal pool _____________ Cervical scrape __________ Endocervical specimen ____________ Other (if indicated) ______________________________________________________________ Complete acetic acid wash _________________________________________________________ Inspect vaginal wall as speculum is removed. __________________________________________ D. Bimanual examination Cervix Consistency _______________________________ Mobility ___________________________ Tenderness with motion ________________________________________________________ Uterus Size and shape _____________________________ Consistency ________________________ Position ___________________________________ Mobility __________________________ Tenderness ___________________________________________________________________ Adnexa Able to palpate? (Be honest.) ____________________________________________________ Size and shape of ovaries _______________________________________________________ Tenderness __________________________________ Masses __________________________ Rectovaginal examination __________________________________________________________

Jarvis, Carolyn: PHYSICAL EXAMINATION AND HEALTH ASSESSMENT: Seventh Edition, Laboratory Manual. Copyright © 2016, 2012, 2008, 2004, 2000, 1996 by Saunders, an imprint of Elsevier Inc. All rights reserved.

CHAPTER 26

Female Genitourinary System

251

REGIONAL WRITE-UP—FEMALE GENITOURINARY SYSTEM Summarize your findings using the SOAP format. Subjective (reason for seeking care, health history)

Objective (physical examination findings)

Record findings on diagram below.

Assessment (assessment of health state or problem, diagnosis)

Plan (diagnostic evaluation, follow-up care, patient teaching)

Jarvis, Carolyn: PHYSICAL EXAMINATION AND HEALTH ASSESSMENT: Seventh Edition, Laboratory Manual. Copyright © 2016, 2012, 2008, 2004, 2000, 1996 by Saunders, an imprint of Elsevier Inc. All rights reserved....