Thursday's Clinical Patients

I saw 5 patients and they were mostly annual physicals and birth control renewals, although one does not have to have a physical exam to receive birth control. This is what the typical exams look like:

1. Introduce yourself to the woman, ask her how things are going. If she doesn't talk much, you specifically ask about school (I'm at a university health center doing women's clinic), work, stress, eating and physical activity. The you ask if she has concerns. Most of the time they say "no" until you're in the middle of the physical exam.

2. Tell her what you plan to do (physical, etc) and ask if that's ok.

3. You leave the room, she changes, you come back and do the following:

• palpate (feel/touch) the thyroid


• listen to her heart (I do three points)


• listen to her lungs (I listen in four quadrants, plus right middle lobe)


• clinical breast exam - at which time you ask about self breast exams (does she do them? does she know how? how often does she do it? etc)


• then you do the pap smear (for cervical cells) and gen probe (for gonorrhea & chlamydia - yes we do it on everyone, unless she says "no" when you tell her what you're going to do today)


• last, do the bimanual exam
  

While doing the exam I ask about her vaginal hygiene (ie: do not douche, try to avoid perfumey products, etc), whether sex is painful (a LOT of women say "yes" which makes me go into another list of questions to ascertain whether it's positional or other), and whether they have anything out of the ordinary for them going on.

Then I leave, they get dressed, I come back and we sit down again and talk about safe sex (you wouldn't believe how many women are not using protection) and safety in general (domestic violence, drinking, and drugs), and about the free mental health services available for free next door (also on campus) if they should ever need anything. We talk about anxiety and stress management right now because it's midterm time, and we talk about smoking cessation if they smoke. If they are renewing their birth control subscription, we go over the risks, use, and benefits of the method they're using just like it's the first time they're ever hearing it, and write the prescription or sell them the discounted methods we have in the office.

We set up the next appointment, and they're off and back in the world!

Outside of this, last week I had a woman who was 32 and had been on Depo Provera for more than 10 years. The protocol in our clinic is to take women off Depo after 10 years because of the black box warning for risk of decreased bone density and osteoporosis. This was also the protocol of her primary physician, but she refuses to go off the Depo. So, she gets bone-density scans every year or two, does increased weight bearing exercise, and takes calcium and vitamin D supplements. I got a taste of "charting for litigation" when i had to chart my conversation with her advising her to go off Depo, and her subsequent refusal. I had to chart the other methods I suggested, and her response to them (a very simple "no") and then wrote the prescription for Depo because it was her choice.

Now, back to studying patho. I'll be glad when this exam is over tomorrow.