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INTRODUCTION

Serving as both specialist and primary care provider, gynecologists provide patient screening, emphasize ideal health behaviors, and coordinate appropriate consultation for care beyond their scope of practice. Various organizations provide regularly updated preventive care recommendations. Guidelines commonly accessed are those from the American College of Obstetricians and Gynecologists (ACOG), Centers for Disease Control and Prevention (CDC), U.S. Preventive Services Task Force (USPSTF), and American Cancer Society.

MEDICAL HISTORY

During a comprehensive well woman visit, patients are first queried regarding new or ongoing illness. To assist with evaluation, complete medical, social, surgical, and family histories are obtained. Specific gynecologic topics usually cover current and prior contraceptives; results from prior sexually transmitted disease (STD) testing, cervical cancer screening, or other gynecologic tests; sexual history, described in Chapter 3; and menstrual history, outlined in Chapter 8. Obstetric questions chronicle circumstances around deliveries, losses, or complications. Screening for intimate partner violence or depression is also completed (Chap. 14). Discussion might also assess the patient’s support system and any cultural or spiritual beliefs that might affect her general health care. Last, a review of systems, whether performed by the clinician or office staff, can add clarity to new patient problems.

PHYSICAL EXAMINATION

Breast Examination

Many women present to their gynecologist with complaints specific to the breast or pelvis. Accordingly, these are often areas of increased focus, and their evaluation is described here.

Self breast examination (SBE) is an examination performed by the patient herself to detect abnormalities. In contrast, clinical breast examination (CBE) is completed by a health care professional and may identify a small portion of breast malignancies not detected with mammography. In addition, CBE may identify cancer in young women, who are not typical candidates for mammography (McDonald, 2004). Overall, however, studies show that SBE and CBE raise diagnostic testing rates for ultimately benign breast disease and are ineffective in lowering breast cancer mortality rates (Kösters, 2008; Thomas, 2002). Accordingly, several organizations have removed SBE and CBE from their recommended screening practices (Oeffinger, 2015; Siu, 2016). However, the American College of Obstetricians and Gynecologists (2017b) encourages breast self-awareness, which focuses on breast appearance and architecture and may include SBE. It also recommends that women receive a CBE every 1 to 3 years between ages 20 and 39. At age 40, CBE is completed annually. Specific mammography guidelines are listed in Chapter 13.

During CBE, the breasts are initially viewed as a woman sits on the table’s edge with hands placed at her hips and with pectoralis muscles flexed. Alone, this position enhances asymmetry. Additional arm positions, such as placing arms above the head, do not add vital information. Breast skin is inspected for breast erythema; retraction; scaling, especially over the nipple; and edema, which is termed peau d’orange change. The breast and axilla ...

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