well-woman annual health ASSESSMENT ^194 ^316 ^331 ^412

The annual health assessment (“annual examination”) is a fundamental part of medical care and is valuable in promoting prevention practices, recognizing risk factors for disease, identifying medical problems, and establishing the patient-physician relationship.

Recommendations for preventive services have been issued by a num­ber of health care organizations in addition to the American College of Obstetricians and Gynecologists (the College) and differ somewhat in their specifics. The Agency for Healthcare Research and Quality acts in part as a clearinghouse for evidence-based clinical practice guidelines, thus provid­ing a readily available means for clinicians to compare different guidelines for a specific medical condition or intervention. The National Guideline Clearinghouse can be found at www.guideline.gov.

The recommendations discussed in this section have been selected from many sources, and they describe routine assessments for women based on age group and risk factors. (Adolescent preventive services are addressed in the “Adolescents” section later in Part 3.) These assessments, yearly or as appropriate, include screening, evaluation, counseling, and immuniza­tions. Variations to routine assessments may be required to adjust to the needs of a specific individual. For example, certain risk factors may influ­ence additional assessments and interventions. During evaluation, the patient should be made aware of high-risk conditions that require targeted screening or treatment. The College has comprehensive recommendations and resources for the annual health assessment of women available online at www.acog.org/wellwoman.

Importance of the Annual Visit

Obstetrician-gynecologists have a tradition of providing preventive care to women. An annual visit provides an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks. Annual visits for reproductive and well-woman care are recommended, even if individual components of that visit (eg, cervical cancer screening) may not be indicated each year. The annual health assessment should include screening, evaluation and counseling, and immunizations based on age and risk factors. The interval for specific individual services may vary for individual patients, and the scope of services provided may vary in dif­ferent ambulatory care settings. The performance of a physical examination is a key part of an annual visit, and the components of that examination may vary depending on the patient’s age, risk factors, and physician prefer­ence. In general, the physical examination will include obtaining standard vital signs, determining body mass index (BMI), palpating the abdomen and inguinal lymph nodes, and making an assessment of the patient’s overall health. Many, but not all, women will have a pelvic examination and a clinical breast examination as a part of the physical examination. Information on these core elements of the physical examination is pro­vided later in this section.

In particular, adolescents, the elderly, and individuals with medical, psychologic, or social issues may have needs that require more than the standard time allotted. It may not be possible to address all of the patient’s concerns in one visit; the physician and patient will need to prioritize med­ical problems, and additional visits may need to be scheduled. In addition, if a clinician believes that a patient’s health interests are jeopardized by the policies of her medical insurance plan, he or she should consider making an appeal to the plan or medical director.

The decision to perform an internal pelvic examination, breast examina­tion, or both should be made by the physician and the patient after shared communication and decision making.

Medical History

A comprehensive medical record should be kept and updated periodically, including medical history, physical examination, and laboratory and radi­ology results. Information from referrals and other medical services outside the purview of the obstetrician-gynecologist should be integrated into the medical record.

Conducting an Interview

The diagnostic process begins when the health care provider meets the patient. When obtaining the patient’s medical history, the health care provider should greet the patient by title and name, make eye contact, shake hands, and be welcoming. The physical environment can enhance the quality of the interview. Whenever possible, the interview should take place in a quiet, private, well-lit room with comfortable and adequate space and seating, with the patient dressed. Instruments that may be intimidating should be covered.

As much as possible, allow the patient to express her story in her own words. Listen without interruption, and be aware that the presence of fam­ily members could be an impediment to an honest interview, especially in cases of intimate partner violence. If the family is present, include time in the interview for a private conversation in the absence of family members. Communication is the key to a successful medical history interview (see Box 3-2). The health care provider should make the patient comfortable enough to speak freely, and the questions should be understood easily and be tailored to the individual patient.

Box 3-2. The RESPECT Communication Model

Rapport

Connect on a social level.

See the patient's point of view.

Consciously suspend judgment.

Recognize and avoid making assumptions.

Empathy

Remember that the patient has come to you for help.

Seek out and understand the patient's rationale for her behaviors or illness. Verbally acknowledge and legitimize the patient's feelings.

Support

Ask about and understand the barriers to care and compliance.

Help the patient overcome barriers.

Involve family members, if appropriate.

Reassure the patient that you are and will be able to help.

Partnership

Be flexible with regard to control issues.

Negotiate roles, when necessary.

Stress that you are working together to address health problems.

Explanations

Check often for understanding.

Use verbal clarification techniques.

Cultural Competence

Respect the patient's cultural beliefs.

Understand that the patient's view of you may be defined by ethnic or cultural stereotypes.

Be aware of your own cultural biases and preconceptions.

Know your limitations in addressing medical issues across cultures.

Understand your personal style and recognize when it may not be working with a given patient.

Trust

Recognize that self-disclosure may be difficult for some patients.

Consciously work to establish trust.

Modified with permission from Mutha S, Allen C, Welch M. Toward culturally competent care: a toolbox for teaching communication strategies. San Francisco (CA): Center for the Health Professions, University of California; 2002.

The goal of a medical history interview is to gather pertinent and basic information about the patient’s health status. A health care provider should consider all aspects of the patient’s presentation and condition and prioritize areas for further evaluation. The health care provider should be aware of the influence of social, economic, and cultural factors in shap­ing the nature of the patient’s concerns and her descriptions of health status and symptoms. Issues of cultural competency and barriers to effec­tive communication must be examined and addressed when developing patient communication and documentation systems. Clinicians and staff members should be aware of the “culture of medicine” and their own cultural attitudes. Increased sensitivity to cultural issues can facilitate more positive interactions and help the patient feel comfortable with her health care team. Patient communication procedures should respect cultural dif­ferences in the role of the extended family in health care decision making, religious beliefs, and the role of traditional and alternative remedies. In addition, clinicians should be attuned to the possible intimidation that may be felt by patients with little exposure to the health care system. The volume of paperwork and the use of professional jargon often associated with health care information systems can be overwhelming.

Mutual trust and respect in the patient-clinician relationship helps to facilitate a complete history. This is particularly important when addressing questions and concerns about sexuality. An awareness by the clinician of his or her own biases and a nonjudgmental approach by the clinician are essential for effective counseling. Box 3-3 includes an example of a sexual history questionnaire from the College’s Women’s Health Record (see also the “Sexual Function and Dysfunction” section in Part 4).

Many common diseases that affect women’s health can be moderated or controlled by behavioral change. However, effectively promoting changes in a patient’s behavior, such as dietary and exercise habits, alcohol use, or sexual practices, can be difficult for the health care provider and the patient. The use of motivational interviewing techniques has been shown

Box 3-3. Sexual History Questions ^

• Have you ever had sex? _

• Are you currently sexually active (vaginal, oral, anal)? _

• Number of sexual partners (lifetime): _

• Sexual partners are:___ men___ women____ both

• Sexual orientation and gender identity:_____ heterosexual____ homosexual

_______ bisexual___ transgendered

• Relationship status:___ married___ living with partner____ single___ widowed

__divorced

• Number of people in household: _

• Have you been sexually abused, threatened, or hurt by anyone? _

Reprinted from American College of Obstetricians and Gynecologists. The women's health record. Washington, DC: American College of Obstetricians and Gynecologists; 2011.

to be effective in promoting behavioral change. With this technique, the physician helps the patient identify the thoughts and feelings that cause her to continue unhealthy behaviors and helps her to develop new thought patterns to aid in behavior change. This technique is implemented most effectively after the physician has established a trusting rapport with the patient. By expressing empathy, providing personalized feedback, and supporting the patient’s ability to help herself, the physician creates an effective interaction for helping promote behavioral changes and better health.

Content of the Medical History

Information contained in the medical history includes discussions of the chief complaint, history of present illness, review of systems, history of past illnesses, family history, social history, and sexual history. Because many patients are reluctant to volunteer problems of urinary and fecal inconti­nence, substance use, sexual dysfunction, or current or past intimate part­ner violence, abuse, or sexual assault, women should routinely be asked about these conditions. Direct and behaviorally specific questions gener­ally result in more accurate responses about these sensitive issues (see also the “Abuse” section later in Part 3).

In 1995 and 1997, the Health Care Financing Administration (currently known as the Centers for Medicare & Medicaid Services [CMS]) developed Medicare documentation guidelines for problem-oriented evaluation and management services (see the CMS Medicare Learning Network at www.cms.gov/MLNGenInfo). These guidelines, developed jointly by the American Medical Association and the CMS, provide physicians and claims reviewers with advice about preparing or reviewing such documentation. Physicians can use either the 1995 or 1997 guidelines, depending on which one is most appropriate for their practice. The difference between the two sets of guidelines is in the examination only. Many practices have modi­fied their medical records to reflect the requirements specified by the CMS, and these requirements typically are included in electronic health records. These requirements are reflected in the Woman’s Health Record produced by the College.

The levels of services described by the CMS are based on four types of history: 1) problem focused, 2) expanded problem focused, 3) detailed, and 4) comprehensive. Each type of history includes some or all of the following elements:

• Chief complaint

• History of present illness

• Review of systems

• Past, family, and social history

The extent of history of present illness; review of systems; and past, family, and social history that is obtained and documented depends on clinical judgment and the nature of the presenting problem.

Chief Complaint

The chief complaint is a concise statement describing the symptom, prob­lem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter. It usually is stated in the patient’s words.

History of Present Illness

The history of present illness is a chronologic description of the develop­ment of the patient’s present illness. It describes the illness from the first sign or symptom or from the previous encounter to the present.

Review of Systems

The review of systems is an inventory of body systems that is obtained through a series of questions seeking to identify signs and symptoms that the patient may be experiencing or have experienced. For example, a history related to breast disorders would include duration, onset, and cyclicity of signs and symptoms, including any breast discharge; men­strual and reproductive history; hormone use; dietary habits; and breast surgery, including implants. The Woman’s Health Record published by the College includes a review of the systems recognized by the CMS. The importance of the review of systems is highlighted in the case of ovarian cancer; a high index of suspicion for persistent and progressive symptoms, such as an increase in bloating, pelvic or abdominal pain, or difficulty eating or feeling full quickly, provides the best way to detect early ovarian cancer.

Past, Family, and Social History

The past, family, and social history consists of a review of general medical, surgical, obstetric and gynecologic history; family health history; allergies; current medications; and sexual and social history. Clinicians also should ask patients about their level of physical activity (eg, frequency, intensity, and timing), provide counseling to promote a healthy weight and lifestyle, and document this in the patient’s medical record (see also the “Fitness” section later in Part 3).

Implementation of a medication reconciliation process is a National Patient Safety goal of The Joint Commission. After the patient provides and the clinician documents a list of the patient’s current medications, a process is required to compare this list to a list of new medications to be provided. In addition, The Joint Commission requires that a complete list of the patient’s medications be communicated to the next provider of care when a patient is referred or transferred.

Patients should be asked about their use of or exposure to substances that could be harmful to their health. Asking patients questions about their use of “medications” or “drugs” may not elicit answers related to the use of over-the-counter medications or complementary and alternative medi­cines. Most patients who use complementary and alternative medicines do not tell their physicians they are doing so. Thus, their medical record is incomplete, and the possibility of medical risk cannot be adequately addressed. Patients can be asked questions similar to “Have you used, or have you been considering using, other kinds of treatment or medications for relief of your symptoms or to maintain wellness?” Follow-up questions to a positive answer can include asking when the patient decided to use complementary or alternative medicines, what results she was expecting, how she chose the method, and how it has worked for her. This informa­tion then can be documented in the patient’s medical record (see also the “Complementary and Alternative Medicine” section later in Part 3).

General Physical Examination

The general physical examination serves to detect abnormalities suggested by the medical history as well as unsuspected problems. Specific informa­tion the patient gives during the history should guide the practitioner to areas of physical examination that may not be surveyed in a routine screen­ing. The extent of the examination is based on the practitioner’s clinical relationship with the patient, what is being medically managed by other clinicians, and what is medically indicated. Once a problem has been iden­tified, intervention can take the form of behavior modification, additional monitoring, treatment, or referral, as necessary. The focus of a preopera­tive examination will depend on the procedure (see also the “Ambulatory Gynecologic Surgery” section in Part 4).

The recommendations for periodic health assessment from the College include weight, height, and blood pressure measurements. Body mass index, which takes into account height and weight and provides the best general assessment of weight, should be calculated. (Calculations for BMI and a link to a BMI calculator are provided in the “Fitness” section later in Part 3.) Clinicians should offer patients appropriate interventions or referrals to promote a healthy weight and lifestyle (see also the “Fitness” section later in Part 3). Classification of blood pressure should be based on the average of two or more readings (see also the “Cardiovascular Disorders” section later in Part 3).

Clinical Breast Examination

For women aged 20-39 years, the performance of a clinical breast examina­tion is recommended every 1-3 years. A clinical breast examination should be performed annually for women aged 40 years and older. Detailed rec­ommendations for the performance of clinical breast examinations are available (see Bibliography). Currently, there is an evolution away from teaching breast self-examination and toward the concept of breast self­awareness. The College, the American Cancer Society, and the National Comprehensive Cancer Network endorse breast self-awareness, which is defined as women’s awareness of the normal appearance and feel of their breasts. Breast self-awareness should be encouraged and can include breast self-examination. Breast self-examination instruction should be considered for high-risk patients. Women should report any changes in their breasts to their health care providers.

The clinical breast examination involves both visual assessment of skin changes and palpation. A visual examination should be performed while the patient is sitting or standing with her hands on her hips. The axillary and supraclavicular areas should be palpated to detect adenopathy. To assess any palpable dominant mass, the examiner should use the fingertips to palpate all of the breast tissue, including the axilla, with the patient in the upright and supine positions. The presence of nipple discharge should be ascertained by gentle pressure. A palpable mass, skin changes, breast pain, or nonlactational nipple discharge requires evaluation, which may include a follow-up examination or additional diagnostic testing (see also the “Cancer Screening and Prevention” section later in Part 3).

Patients should be encouraged to undergo screening by mammography in accordance with College guidelines (see also the “Cancer Screening and Prevention” section later in Part 3). Women should be educated about the predictive value of screening mammography and the potential for false-positive or false-negative results. Women should be informed of the potential for additional imaging or biopsies that may be recommended based on screening results.

Obstetrician-gynecologists may diagnose and manage (consistent with their training and experience) or refer for treatment those patients with a solid or cystic breast mass, a mammographic abnormality, breast pain, physiologic and abnormal nipple discharge, mastitis, or fibrocystic changes of the breast (see also the “Cancer Diagnosis and Management” section in Part 4). Institutions that grant physicians privileges to perform breast surgery should apply the same criteria for privileging to obstetrician­gynecologists as to other physicians.

When a nonpalpable mass is perceived on screening mammography, the patient should be referred to a professional experienced in the diag­nosis of breast cancer. When a patient is referred to another physician for diagnostic testing or consultation, the obstetrician-gynecologist should ensure that the patient is provided with the following:

• An explanation that she needs further care

• The names of qualified physicians from whom the patient can receive care

• An opportunity to have her questions answered

• A summary of the history, physical examination, and diagnostic tests performed

• Information for the consultant if diagnostic imaging is required for a reason of clinical concern rather than merely routine screening

Documentation of these steps and a description of the clinical findings should be included in the medical record.

Pelvic Examination

The pelvic examination includes three elements: 1) inspection of the exter­nal genitalia, urethral meatus, vaginal introitus, and perianal region (exter­nal examination); 2) speculum examination of the vagina and cervix; and 3) bimanual examination of the uterus, cervix, and adnexa (the latter two elements constitute the internal examination). When indicated, a recto­vaginal examination also should be performed. Annual pelvic examination of patients 21 years of age or older is recommended by the College. At this time, this recommendation is based on expert opinion, and limitations of the internal pelvic examination should be recognized. A pelvic examina­tion always is an appropriate component of a comprehensive evaluation of any patient who reports or exhibits symptoms suggestive of female genital tract, pelvic, urologic, or rectal problems.

External Examination

After emptying her bladder, the patient should be assisted to the lithot­omy position and properly draped. Other positions may be appropriate, depending on the age or physical limitations of the patient (see also the “Pediatric Gynecology” section and the “Women With Disabilities” sec­tion later in Part 3). Careful inspection of the vulva and perianal area with adequate lighting is performed first. The labia are then gently separated to allow visualization of the urethral meatus and introitus. The clinician should carefully note and record any pertinent findings.

Speculum Examination

After the external examination, a warm speculum of appropriate size should be inserted gently into the vagina, with posterior pressure against the perineal and levator muscles until the cervix can be visualized entirely. If the speculum does not pass easily, it may be moistened with water. If lubricant is used, care should be taken to avoid contaminating any sample, because lubricant can interfere with the interpretation of results of conven­tional cervical cytologic studies and with the growth of microorganisms if a culture is taken. After adequate inspection of the cervix and vaginal fornices has been performed, the speculum should be slowly removed so that the vaginal walls can be inspected.

If appropriate, a sample for cervical cancer screening is obtained (see also the “Cancer Screening and Prevention” section later in Part 3). If abnormal vaginal or cervical discharge is noted, or if the history indicates, appropriate sample collection and testing for sexually transmitted infec­tions should be performed. Routine annual screening for chlamydial infection and gonorrhea is recommended for all sexually active women aged 25 years and younger and for other asymptomatic women at high risk of infection (see also the “Sexually Transmitted Infections” section later in Part 3). Nucleic acid amplification tests for gonorrhea and chlamydial infection can be performed on urine or vaginal swab specimens. If a pelvic examination is not indicated, appropriate screening for chlamydial infec­tion and gonorrhea may still be carried out with a self-collected vaginal swab or a first-catch urine specimen.

Bimanual Examination

After completion of the speculum examination, a bimanual examination is carried out to evaluate the vagina and the cervix and the size, shape, and position of the uterus. The adnexa are then examined for size, shape, and tenderness.

When indicated, a rectovaginal examination should be performed as the last part of the examination to evaluate the rectovaginal septum, the posterior uterine surface, the adnexal structures, the uterosacral ligaments, and the posterior cul-de-sac. Uterosacral nodularity or posterior uterine tenderness associated with pelvic endometriosis can be assessed in this manner. In addition, this examination may identify hemorrhoids, anal fissures, sphincter tone, and possible rectal polyps or carcinoma. Taking a stool sample for fecal occult blood testing during the digital rectal exami­nation is not recommended because it is not adequate for the detection of colorectal cancer (see also the “Cancer Screening and Prevention” section later in Part 3).

Bibliography

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