YOU WERE LOOKING FOR: Pelvic Exam Template
Consent forms are not only for the protection of the patients but also for the doctors. The way men conduct themselves toward women has progressed in the right direction, but that direction could lead to walking off a cliff. This generational gap...
The actions of Tyndall, Nassar and other doctors who took advantage of their position are emblematic of the epidemic plaguing college campus health centers across the nation. A pelvic exam consent form would help minimize the risk of any potential...
Before performing the pelvic exam, your doctor might listen to your heart and lungs and perform an abdominal, back and breast exam. During the pelvic exam Pelvic examination Open pop-up dialog box Close Pelvic examination Pelvic examination In a pelvic exam, your physician inserts two gloved fingers inside your vagina. While simultaneously pressing down on your abdomen, he or she can examine your uterus, ovaries and other organs. Pap test Open pop-up dialog box Close Pap test Pap test In a Pap test, your doctor uses a vaginal speculum to hold your vaginal walls apart and to see the cervix. Next, a sample of cells from your cervix is collected using a small cone-shaped brush and a tiny plastic spatula 1 and 2.
Your doctor then rinses the brush and spatula in a liquid-filled vial 3 and sends the vial to a laboratory for testing. You'll lie on your back on an exam table with your knees bent and your feet placed on the corners of the table or in supports stirrups. You'll be asked to slide your body toward the end of the table and let your knees fall open. A pelvic exam generally includes: External visual exam. First, your doctor looks at your vulva, checking for irritation, redness, sores, swelling or other abnormalities. Internal visual exam. Next, your doctor uses a speculum — a plastic or metal-hinged instrument shaped like a duck's bill — to spread open your vaginal walls and see your vagina and cervix. The speculum might be warmed before it's inserted to make it more comfortable for you. Inserting and opening the speculum causes pressure that can be uncomfortable for some women. Relax as much as possible to ease discomfort, but tell your doctor if you're in pain. Pap test. If your pelvic exam includes a Pap test Pap smear , your doctor will swipe a small wand to collect a sample of your cervical cells before removing the speculum.
Physical exam. Because your pelvic organs, including your uterus and ovaries, can't be seen from outside your body, your doctor needs to feel palpate your abdomen and pelvis for this part of the exam. Your doctor will insert two lubricated, gloved fingers into your vagina with one hand, while the other hand presses gently on the outside of your lower abdomen.
During this part of the exam, your doctor will check the size and shape of your uterus and ovaries, noting any tender areas or unusual growths. After the vaginal exam, your doctor will insert a gloved finger into your rectum to check for tenderness, growths or other irregularities. Your doctor should tell you exactly what he or she is doing at each step so that nothing comes as a surprise to you. After the pelvic exam After the pelvic exam is over, you can get dressed. Then, your doctor will discuss the results of your exam. Results Your doctor can usually tell you immediately if the exam revealed anything unusual. Pap test results might take a few days. Your doctor will discuss with you any next steps, additional tests, follow-up or treatment that you need. Your pelvic exam is a good time to talk to your doctor about your sexual or reproductive health.
Sherrell V Patient is sexually active and on oral contraceptives, therefore pap smears are recommended. HEAD: Normocephalic. External auditory canals and tympanic membranes clear bilaterally, hearing grossly intact. No nasal discharge. Oral cavity and pharynx normal. Teeth and gingiva in fair condition. NECK: Supple, non-tender, no adenopathy, masses, or thyromegaly. Scribd is the world's largest social reading and publishing site.
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. It also revealed clue cells wich is clinically significant for the diagnosis of bacterial vaginosis. Thick white discharge suggested vaginosis as reported and noted on examinations suggest vaginosis. Unprotected sex V Healthcare providers need to be fluent in SOAP notes because it provides concise and complete documentation that should describe what you observed, what data you collected, and what you did.
Take full credit for your hard work! This article will break down the basics of how to write a SOAP note with obstetric examples. They are firm, non tender, and without masses or lesions. No penile lesions are noted and there is no discharge from the urethra. The scrotum is without induration, erythema, or edema. Pap smear 2. Endometrial biopsy obtained 3. Medications, etc. Regular menses q 28 days with no intermenstrual bleeding. IUD for contraception since birth of last child 2 years ago.
Normal Physical Exam Template Samples. Related Posts. Physical Exam Medical Transcription Normals. Had first sexual encounter this past summer at age 15 years. Has never had a pelvic exam, and has never been diagnosed with a sexually transmitted disease. Using condoms intermittently. The patient will have to keep visiting the health facility after the procedure for routine maintenance and test to ascertain that the tumor does not regenerate.
The availability of genitourinary imaging should not replace the clinical skills which lead to a possible diagnosis and list of differential diagnoses. It is these that point the clinician towards These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the JS is a 20 year-old Hispanic female who presented to the women's health clinic on June 21, for her first prenatal care. She was last seen by Dr. Vagina was slightly atrophic. Minimal anterior and posterior compartment defects. Well-supported uterus in superior compartment.
Positive cough stress test. SOAP Notes is ideal for any person who must manage detailed notes for each patient visit and needs an app that will enter the notes quickly, and accurately. Cholelithiasis is the formation of cholesterol stones in the gallbladder. Gallstones are twice as common in women as in men. Each of these notes represents very typical patients you will see on the rotation. Look at the way the notes are phrased and the information they contain. Each step presents information on how that case would likely be handled. Questions under each category teach the students important steps in clinical care. The SOAP series is a unique resource that also provides a step-by-step guide to learning how to properly Managing patient's health and illness is shown in Soap Note 6, attachment 1.
These assessments should include screening, evaluation and counseling, and immunizations based on age and risk factors. The interval for individual services Using the palmar surface of your fingers, palpate for the uterine fundus while gently pushing the cervix anteriorly with the pelvic hand. Family planning V By Mark Morgan. Add to Favorites CDC criteria for assessing pregnancy status without a urine test. Tags: note. The pelvic exam revealed no adnexal masses. The uterus appeared to be normal in size and there was no cervical motion tenderness.
Sherrell Ear, Nose, Throat-. Ears: external appearance normal-no lesions, redness, or swelling; on otoscopic exam tympanic membranes clear. Hearing is intact. Nose: appearance of nose normal with no mucous, inflammation or lesions present. Septum is midline. Mouth: pink, moist mucous membranes. No missing or decayed teeth. Vagina and cervix show no lesions, inflammation, discharge or tenderness. No cystocele. No edema. Peripheral pulses intact. No varicosities. SKIN: normal. No dysarthria is noted. No discomfort on presentation is noted. HEAD: Atraumatic, normocephalic. Pupils are equal, round and reactive to light. Extraocular muscles are intact.
Sclerae are white without injection or icterus. To provide quality care for your antepartum patients, you need this item NCLEX style questionnaire that will also challenge your knowledge about Obstetrical Nursing. This exam includes nursing care for pregnant women during the antepartum period. Let us make pregnancy an occasion when we S: HPI: 27 yowf. Setting: health department, hx per pt. Hx: 3w bad smelling discharge from my vagina, thick, white, and seems heavier in the morning, no aggravating or reliving factors noted. Normal exam P.
Importance[ edit ] Although women often undergo well-woman examinations on an annual basis, the interval for this visit and exam will vary depending on the needs of the patient. With the patient in a supine or seated position, the medical professional will look at both breasts to check the color, symmetry, dimensions according to age, lean body mass, the physiological pregnancy and lactation and race, looking for abnormalities, such as bulges and shrinkage. If it is flattened or retracted umbilicated , it is necessary to consider the possibility of a cancerous lesion which has caused the malformation. The patient has to lift the arm and put one hand behind her head. With this position, the entire gland is palpated. It is also important to examine the armpits, because of masses that may be found there. The nipples are also squeezed to check for secretions, such as secretion of milk galactorrhea , serous , blood or purulent secretions.
If a node is detected, it is necessary to determine its place, size, shape, edges, consistency and sensitivity. Breast self-awareness includes being familiar with the normal contour of one's breast but does not involve monthly self-examinations. They are the procedure most likely to detect early breast cancer in asymptomatic women. Mammograms can show tumors long before they are large enough to palpate. They are recommended for women who have symptoms of breast cancer or who are at increased risk of developing the disease. They are performed with the patient standing, the breast pressed between two plastic plates, as the image is taken. The interpretation has to be performed by a specialist. In many women the tissue that makes up the breast is very dense, representing fibrous tissue and glandular tissue, which produces milk during lactation. This limits the radiologist interpreting the study, so, in these cases, the ultrasound is helpful, since this is capable of distinguishing tumors in women with dense breast tissue, where identification is otherwise difficult.
Additionally, it is advisable to follow up a mammogram that shows indications of tumors with an ultrasound, to confirm, before more invasive procedures are undertaken. This exam often includes three parts: Inspection of the external genitalia Bimanual examination Inspection of the cervix and vagina using a speculum. With the feet in these stirrups, the legs are placed in a position such that the medical professional can access the pelvic area.
The external genitalia is examined first, looking for abnormalities like lesions, ulcers, warts and color changes. The elements of this exam include the vulva , which contains the mons pubis , of which there are two longitudinal folds of skin forming the labia majora; then the labia minora and hair follicles. The clitoral hood is also checked. The index and middle finger are inserted into the vagina.
This maneuver allows the doctor to palpate the vagina for any deep lacerations, masses, or nodularity. Next, the cervix is palpated to check position, size, consistency, and mobility. This maneuver allows the clinician to assess the size, shape, consistency, tilt, and mobility of the uterus. With this technique, the ovaries may also be palpable. Its purpose is to separate and widen the vaginal opening and keep it open. This allows direct observation by the physician into the vaginal canal with the help of a lamp or a mirror. The first step is to open the vaginal opening with two fingers at the vulvo-perineal angle, then separate the fingers slightly and press down, then insert the speculum arranging the width of the tip of the flaps in anteroposterior. When the speculum is in place, the fingers are removed and the device is rotated so that the flaps are horizontal.
The flaps are then separated and locked into place when the cervical neck is completely visible. Some women experience temporary bleeding from this procedure. The scrapings are placed on a slide, covered with a fixative for later examination under a microscope to determine if they are normal or abnormal. Sexually Transmitted Infection Screening - Depending on age and risk factors, clinicians may recommend gonorrhea or chlamydia testing at the time of the well-woman exam. This sample can be collected via a swab of the cervix or vagina.
This swab can be collected by the clinician or the patient. Urine samples can also be used for this test. Additional screening tests include blood tests for hepatitis C , HIV , and syphilis.
Expanded problem focused exam — a limited exam of the affected body area or organ system and any other symptomatic or related body area s or organ system s. Detailed exam — an extended exam of the affected body area s or organ system s and any other symptomatic or related body area s or organ system s. Comprehensive exam — a general multisystem exam, or a complete exam of a single organ system and other symptomatic or related body area s or organ system s. The guidelines include a detailed chart that specifies the exam elements that must be performed and documented to justify each level of exam.
In the chart, the shaded headings list the organ systems and body areas as CPT categorizes them. These body areas and systems are worth some attention. Look closely at the terms and the way they are grouped; they may not correspond exactly to those you are used to running through in your mind. This presumably represents recognition that these systems are easier to ask about than to examine. Now, back to the multisystem exam chart.
Parenthetical examples provide clarification and guidance within the chart. Finally, CMS urges you to keep in mind that the use of the documentation guidelines is not a substitute for medical necessity. A well documented service won't automatically be assumed to have been medically necessary.
Anything that hurts or bothers you First a mini-checkup Before the exam, your pediatrician may check your height, weight, blood pressure, lungs, heart, breasts, and stomach. You may be asked to give a small sample of urine and to empty your bladder so the pelvic exam is more comfortable. There are 2 main parts of your exam: the interview and the pelvic exam. Part 1—The interview Before the pelvic exam, your pediatrician will ask you questions about your health and your periods. So don't be surprised if you're asked questions like When did you get your first period?
When was your last period? Do you have your periods regularly? How often? How long do they last? Do you have any pain, cramps, headaches, or mood swings with your periods? Do you use tampons, pads, or both? Have you ever had vaginal itching, discharge, or problems urinating? Do you douche? If yes, how often? Don't be surprised if your pediatrician asks you about sex. You may be embarrassed or feel like your sex life is nobody else's business, but your pediatrician needs to know these things to help you protect your health. So be honest! And don't forget, whatever you say to your pediatrician is confidential and won't be discussed with anyone else without your permission unless it's something life threatening, of course.
No comments:
Post a Comment