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Women's Health
• Focusing on women's health: o Name and describe the components and rationale of the gynecological health history. o Define and describe each component of the GTPAL system used to document pregnancy history. • Following the guidelines of the United States Preventive Service Taskforce (USPSTF) what screening recommendations would you do to G.R. a 66-year-old female patient who visits you at the office for the first time (last visit to her PCP 5 years ago) with only positive health history of hysterectomy 10 years ago due to fibroids. • A 35-year-old women with a BMI of 40 comes in asking about combined hormonal contraception’s. You explain the contraindications for hormonal contraception include (name more than 4 contraindications).
Sample Answer
Here is an outline focusing on women's health history, pregnancy documentation, and preventive screening, tailored to your requests.
🌸 Gynecological Health History
The gynecological health history is a focused and essential component of a woman's overall health record. Its rationale is to establish a baseline, identify risks for cancer, infectious diseases, and pregnancy complications, and guide appropriate screenings and counseling.
Components and Rationale:
Component
Description
Rationale
Menstrual History (LMP)
Age at menarche (first period), frequency, duration, flow, any associated pain (dysmenorrhea), and last menstrual period (LMP).
Identifies abnormalities (e.g., polymenorrhea, oligomenorrhea) and endocrine issues, tracks fertility, and determines due dates for pregnancy.
The GTPAL System for Pregnancy Documentation
The GTPAL system is a standardized, concise method used to summarize a patient's obstetric history.
Component
Definition and Description
G - Gravida
The total number of times a woman has been pregnant, regardless of the outcome (current pregnancy, miscarriages, abortions, and live births all count).
T - Term
The number of pregnancies delivered at 37 weeks 0 days gestation or later (full-term pregnancies).
P - Preterm
The number of pregnancies delivered between 20 weeks 0 days and 36 weeks 6 days gestation.
A - Abortions
The total number of pregnancies ending before 20 weeks gestation. This includes both spontaneous (miscarriage) and induced abortions.
L - Living
The number of children currently living. This count is crucial as it reflects the current family structure and includes situations where multiple births (twins, triplets) occurred during a single pregnancy.
Example: A patient pregnant once before, who delivered twins at 38 weeks, and both are alive, would be documented as G2 P1002 (Gravida 2, Term 1, Preterm 0, Abortions 0, Living 2).
🩺 USPSTF Screening for G.R. (66-Year-Old Female)
Based on the USPSTF guidelines for G.R., a 66-year-old female with a history of hysterectomy 10 years ago due to fibroids, the following screenings are recommended:
Screening Recommendation
Rationale (USPSTF Guidance)
Cervical Cancer Screening (Pap Smear)
Screening is NOT recommended. G.R. is over the age of 65, and with a history of a total hysterectomy (removal of the cervix) for benign reasons (fibroids), she has met criteria for cessation of screening.
Breast Cancer Screening (Mammography)
Screening is recommended (Grade B). The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. Continue screening until age 75.
Colorectal Cancer Screening
Screening is recommended (Grade A). Screening should continue until age 75. Options include High-sensitivity Fecal Occult Blood Test (FOBT), sigmoidoscopy, or colonoscopy.
Bone Density Screening (Osteoporosis)
Screening is recommended (Grade B). Screening for osteoporosis is recommended for women age 65 years and older (via Dual-Energy X-ray Absorptiometry or DXA).
Abdominal Aortic Aneurysm (AAA) Screening
Screening is NOT recommended. Screening is only recommended for men aged 65–75 who have ever smoked.
Lipid Disorders Screening
Screening is recommended (Grade A). Screening for lipid disorders is recommended for women aged 40 to 75 years.
Diabetes Screening (Abnormal Blood Glucose)
Screening is recommended (Grade B). Screening is recommended for adults aged 35 to 70 years who are overweight or obese (BMI $\geq 25 \text{ kg/m}^2$). G.R.'s BMI is unknown, but screening is standard in this age group.