Clinical approach to gynaecological patient (part 2)
CLINICAL APPROACH TO
MBBS, MS. FICOG, MICOG
NIMS medical College ,Jaipur.
Founder Principal & Controller ;
Jhalawar Medical CollegeAnd Hospital , Jhalawar.
Ex. Principal & controller;
MahatmaGandhi Medical CollegeAnd Hospital ,
Sitapur, Jaipur .
Pre requisites for clinical
Thorough clinical examination is essential and
integral part of clinical approach to any patient ; to
reach the provisional diagnosis one should co relate
and analyse the positive as well as negative points
noted in history taking and findings of clinical
On the basis of probable cause; necessary and
relevant investigations should be ordered . , their
interpretations must be done in the light of above
findings and analysis done ___ final diagnosis so
derived is more likely to be exact and true.
Reaching to diagnosis by short history / few clinical
finding is always deceiving.
Pre requisites for clinical
examinations--- Ensure adequate Privacy .
Good and sufficient light (As good as natural color).
Take consent of parent/ guardian if patient is minor / patient herself
A female nurse/ her relative should also stand near by when female
patient is examined., so that intensions of gynaecologist are not
Keep all necessary equipments before patient ‘s examination is
started; weighing machine, measuring tap, height measuring scale
stand ,Bp. Instrument, torch, Pair of gloves, appropriate size and
variety of vaginal speculum, swabs ( dry, soaked with antiseptic),
swab sticks for collection of discharge for office procedure for wet
film- microscopic examination / culture , glass slide and cover slips,
Ayres spatula ,carrying /preservative media and cervical brush for pap
smear , acetic acid 1-5% , Lugols iodine, saline for colposcopy or
simple naked eye inspection of cervical lesion.
This will make the examination quicker, complete and comfortable to
both patient as well as patient.
General physical examination
Height , weight –calculate BMI.
Nails , palms --- for pallor , pigmentation, palmer
arrhythmia, clubbing, platynaechia ,fungal infection of
Carrying angle of elbow in turners .
Axilla –hair growth, lymph nodes .
Neck –Webbing of neck , thyroid goiter, lymph nodes
tubercular chain / healed sinus scar/ wircow’gland in left
supra clavicular region – metastasis in ca cervix / ovary.
Eyes– conjunctiva—pallor, sclera--- jaundice.
Face– hair growth--- hirsutism(use Ferriman-Gallway
score ) / familial hypertrichosis , achne – PCOD / steroid
or OCs therapy.
Skin Pigmentation (palms) in secondary Syphilis
Increased carrying angles, shield chest, no
development of secondary characters , stunted
growth ( height and weight)
7 & ½ years old Girl with well developed
Thalarche, puvarche and regular menses (
Homlogous precocious puberty)
tall girl , primary amenorrhoea. ,
no pubic hair inguinal hernia may
be there containing testicle
absence of testicular receptors at
end organs prevent in
development of wolfian duct, but
neutral development makes one
to look like female ; as mullerian
system development enzymes are
also not secreted by testicles the
mullerin duct development is also
not fully supressed . It remains
under developed as estrogen is
not produced . Brest development
is under adrenal androgens
16 years old girl with 46xx , dysplasia ,
no secondary sex characters yet
developed , reporting as a case of
General Physical Examination
cont-- Scalp—hair loss –secondary to chemotherapy,
receding hair line in musculinizing conditions .
Note --- BP, Pulse , respiration, temperature,
Gait, edema, vericose veins .
Other group of lymph nodes --- inguinal.
Development of secondary sex characters ---
> Breast development.
> Axillary Hair.
> Pubic Hair.
Examination Of Breast
One should never forget to examine the breast
Adolescent girls presenting w2ith
amenorrhea(primary)—may have under /
undeveloped breast for the age and breast
development should be assessed according to
tanner’s staging .
Women with secondary amenorrhea may have
galactorrhoea---Post Pill, prolactin secreting
pituitary tumor, hypothyroidism, drug induced .
Woman. Should be taught to-do self breast
Method of breast examination
Clinical examination of breast should be carried out
with the pads of 3 middle fingers of both hands ,
with the patient(raised arms above her head and
arms by side of her chest ) while she is sitting on
stool / in supine position lying down on examination
Each breast should be examined systematically for
lumps if present –size location mobility ,
consistency and nipple discharge if present should
be collected on glass slide for microscopy.
Compare both the breast in each aspect .
Systematic Breast Examination
Position –sitting with arms raised.
Extent ---lateral boarder of sternum to posterior
maxillary line and from clavicle to costal margin.
Inspection ---col0r of skin, pigmentation , engorged
subcutaneous blood vessels, edema , dimpling , puddie
–orange skin. Nipple retraction , nipple eczema.Any
visible swelling, ulcer, accessory nipple.
Palpation --- nipple discharge , palpable mass / cyst---its
size location, boundaries , mobility , consistency ,
adherent to skin / underlying pectoral muscle,
tenderness, local rise in temperature and surrounding
Regional lymph nodes --- axillary group and
Stepwise Self Examination of
Brest Stand in front of mirror and look at your breast well expose as in previous slide-
Step 1-- to look at breast while standing with arms hanging next to the body .
Step2– Look at breasts when arms are behind your head.
Step 3– look at breasts while arms are by the side with hands resting at hip
What to look for ?
Look for any change or difference in color, size shape, dimpling , any visible
prominent swelling in any part of either breast. Look for any in drawing /
retraction of nipple.
Step 4– feeling of( palpation ) whole surface and consistency of either breast
with flat of all the fingers pressed firmly against breast( right hand for left and
left hand for right breast ) in a circular fashion ; starting from areola to its
margins e.g from chest bone to the fold of arm pit and from collar bone to lower
limits of rib boarder. Brest is even and any abnormality can be appreciated easily
in the form of nodule/ swelling . . Feel the arm pit for ant nodule / swelling in the
tail of the breast / lymph nodes.
Step 5--- Nipple is picked in thumb and index finger, lit it out , sqeez for any
discharge --- milk, watery/ blood stained.
Step 6--- Feel for breast and nipple in the same manner as in step 4&5 , but
CVS– heart sounds, any murmur , parasternal heave , Epigastric
pulsation, prominent jugular veins. Compare all the peripheral
pulses in cases of turnner’s syndrome as coarctation of aorta
may co –exist.
Respiratory system--- Rate, breath odour, cynosis , clubbing ,
breathlessness at rest / exertion/ bilateral lung examination---
air entery, chest movements, percussion (any dullness or hyper
resonance) , breath sounds and adventitious sounds(
crepitation , ronchi, plural rub etc).
Spine-- scoliosis, lordosis. Kyphosis, fracture spine / tenderness
over any spinal vertebra especially in menopausal women .
Mental function – orientation to place, time . Pituitary dwarf
are intelligent and have poor sex development while thyroid
dwarfs are having low IQ.
CNS--- when intra cranial lesion is suspected.
Inspection---color of skin, pigmentation , caput
medusa, prominent veins and direction of blood
flow in them, protrusion of umbilicus/ its
displacement. Umbilical slitting –transverse or
vertical, thoraces-abdominal respiration , shape(
saphead / distension may be due to fat , as cites,
fetus , mass. Distended bladder, flatus and
faeces).Hernia sites ,striae gravidorum , linea
nigrans and albicans, bruises ., visible pulsations ---
intestinal / aneurism of abdominal aorta.cunter
irritation marks/ scar of previous surgery.
Palpation should be started from the are which has no pain .
Palpate for liver , spleen and kidney enlargement if any present
and describe it well in terms of size, shape margin ,consistency
surface, margin and tenderness ?
If mass is present – its localization and extension in abdominal
quadrant quadrants; is it arising from pelvis (lower pole can not
be reached as it is below symphysis pubis joint) ,is it arising in
abdomen and growing down?.
feel for its shape, margins all round, consistency(soft, solid . Firm.
Hard, variable , mobility—(up --down , side to side or tangential
to line of attachment of mesentery, does the abdominal wall
moves over it with respiration), nodularity , oblation.
Any tenderness ,muscle guarding / rigidity. Rebound tenderness.
For generalized dull note --- ascites ,fluid thrill and
shifting dullness can be noted.
Abdominal mass maybe dull with in its boundary ( if
cystic fluid thrill may be present) rest abdomen will
be resonant as in cases of large ovarian cyst /
Solid tumors will be dull.
Hyper resonant abdomen present in cases of
intestinal obstruction due to distended bowel loops
Liver dullness is obliterated in intestinal perforation /
or after pneumoperitoneum create in laparoscopy.
Very useful to auscult intestinal sounds --- if
absent, paralytic ileus –high pitched
exaggerated sounds in intestinal obstruction ;
rarely a bruit may be heard on hyper vascular
Pulsatile tumor may be aortic aneurism / solid
tumor sitting over normal aorta may also
conduct sound .
Bruit in renal angle present in cases of renal
artery aneurism ---- secondary Hypertension
Examination of Female Genital
Tract Positions --- dorsal, left lateral ( sim’s ), Knee elbow .
Examination is usually performed in dorsal position with hip
and knee flexed and feet resting on the examination couch .
Her buttocks are brought down to the edge of tail end of the
Lithotomy position with legs in strips is to combersom to
patient for examination in OPD. It is used in MOT while doing
short office procedure with / with out sedation.
Gynaecologist stands on her right side nearer to her foot end.
Head of patient can be with pillow raised to relax the
Examination is conducted in the same order as described in
Lithotmy postion for office procedure and surgery through vaginal route
Examination 0f Child
Examination of small child
by putting Her in the lap Of
Candidasis of vulva in Child Girl with Dermatitis
Botryoid Sarcoma Protruding throughVaginal Introitus in Girl
Vaginal Per Speculum
Dryness / discharge
Bleeding from vaginal
Sqamo columnar Junction
Transitional Zone .
Nebothian Follicle / cyst
Polyp / growth/ protruding IUCD thread
Bleeding on touch
Bleeding through os
Examination after application of acetic acid
and Lugol’s iodine with naked eye if needed
---Colposcopy as office procedure
Abdomino- pelvic Bimanual Examination
Gloved, lubricated index and middle fingers are insert in vagina
after cleaning vulva and vestibule with antiseptic lotion and
separating both labia with the finger and thumb of left hand.
Once internal finger reach the cervix the palmer surface of all
fingers of left hand are placed parallel to S.P. over supra pubic
Direction of cervix is decide – forte ward ( if external is facing to
and anterior lip is near to S.P. / Backward when external os is
facing posterior fornix and anterior lip is facing posterior
vaginal wall. Feel for its consistency(soft in pregnancy / firm –
normal / hard in malignancy . tender Cx on movement ---
ectopic/ acute inflammation. Ulcer / protruding growth /polyp /
valvety erosion and IUCD thread may also be felt ; protruding
down in / through cervical canal , slippery shaft , smooth
mucous polyp may some time be present.
Abdomino- pelvic Bimanual
Examination Now put your both fingers in posterior fornix ,
uterus is pushed upward and anteriorly towards
the abdominal hand and uterus is palpated
between two hands --- its size , shape , surface ,
consistancy and tenderness.
If uterine fundus and its posterior surface can be
palpated ---uterus is ante flexed (AF) ante verted
(AV) , if uterus can not be lifted and its fundus is
posterior in POD ---it is retro flexed (RF) and
retro verted ( RV )
Abdomino- pelvic Bimanual Examination
The normal uterus is anteverted, anteflexd , pear
shaped firm,6-7 cm long and 4cm wide at its
fundus. mobile regular and non tender.
Normal adnexa is not palpable , all fornices are
free / empty, non tender .
Ovaries are about3x2 cm in size and usually not
palpable unless enlarged.
Palpable ovary in menopausal women should be
viewed with suspicion.
Abdomino- pelvic Bimanual Examination
Vaginal fingers are now to lateral (right and left )
fornices respactvely to palpate ; while abdominal
hand is placed just medial to ipsilateral
anteriosperior iliac spine well above the poupart’s
ligament and adnexa is palpated in between two
Some time to palpate thickening / induratin /
infiltration in recto vaginal fascia one has to
per0form bimanual rectal and vaginal examination
at the same time ---index Finger in vagina and
middle finger in rectum with their pulp facing
anteriorly; left hand is put on abdomen as usual for
performing bimanaual palpation.
Bimanual Pelvic Examination – PV and PR simultaneously; to palpate the involvement of
anterior Rectal and posteriorVaginal wall By malignancy / Endometriosis
Bimanual examination – findings to be
Anteverted / anteflxed / midposition / shifted to
right or left side of mid line/ retroverted /
Size—normal / enlarged ( measured in terms of
enlargement as in gestational period )
Shape –regular/ irregular
Surface – smooth / bossed / uneven
consistency– firm / soft / heard / variable
Mobility– mobile / fixed / restricted.
Tenderness– absent / present
Bimanual examination – findings to be
Palpable / not palpable
size –in approx Cm in all diameters—longitudinal / transverse / oblique.
Surface – regular smooth / nodular / lobulated.
Unilateral / bilateral
consistency--- soft/ cystic / firm / hard / variable.
Mobility --- mobile/ fixed / restricted .
Tenderness --- absent / present .
Attachment to uterus --- does it move with uterus or cervcal movements /
while moving the adnexal mass uterus/ cervix also move .
3. Pouch Of Douglas
Any mass / thickening nodules fixed / fullness / tenderness / raised local
temperature / consistency of mass / fullness.
4.Per rectal Examination
thickening / indurations / adherent / ulcerated anterior rectal wall / sacral
ligament / recto vaginal fascia.
PV examintion in OvarianTumor __lump is separate from normal sized
pelvic mass in left Fornix lateral and separate from Uterus , there is
free area ( cleavage in between Cervix and medial side of lower
pole of tumor
Cleavage/ free area
Differentiating uterine from adnexal
Criterias Uterus Adnexal mass
Location Central lateral
Size normal in size uterus / if
enlarged its size varies
Palpable if enlarged
Groove between mass and
Transmitted mobility present Absent
Children, adolescent and old women present special situation.
Children – local examination of vulva and vestibule should be
examined in presence of and with the help of her mother in
separating thighs and labia apart, speculum and pv
examination is not done if indicated ; it can be done under
general anaesthesia by using nasal speculum . Pr with little
finger will replace pv examination.
Adolescent Girls avoid speculum/ pv examination , pr can be
done, if pathology is highly suspected USG can help ; still some
vaginal examination / procedure is must the it should be done
after proper counselling , proper consent and under sedation /
Post menopausal women with narrow introitus due to estrogen
deficiency --- small size speculum with lubrication should be
Screening / diagnostic procedures done
at the time of gynaecological
Pap Smear .
Examination of vaginal / cervical/ nipple
discharge. A- saline preparation ; B- KOH
preparation ;C- Gram staining.
Current Recommendations For Pap
Start at the age of 21 year --- if sexually active.
Once in 2 years till 30 years age .
Once in 3 years there after --- if HVP DNA
negative , low risk factors present for developing
Ca Cervix, last 3 samples are negative.
Annual Screening ---High risk for cancer / HVP
Stop at 65 age if no positive smear in last 10
Diagnosis of vaginitis by Examination Of
Wet Film KOH Preparation Gram Stain
discharge with bad
Clie Cells Fishy odour (Amine)
T.Vaginalis Vaginitis (
cream colored frothy
vag. Dis.With burning
Candida Albicans (
thick curdy vag. Dis.
With itching at vulva)
Fungal Hyphae ,
( dysurea, mailase
Gram Negative , intra
Clue cells in Vagnalis vaginosis (Squamous
Epithelium Cells Loaded with Anerobes –
Large Motile Protozoa--- Trichmonas
Inclusion Bodies in