The gynaecological history taking and physical examination Dr YAY MON KYAW
History taking• Patient identification-Name, age, parity, occupation.• A brief statement of the genernal nature and duration of the main complaints.• History of presenting complaints.• Abnormal menstrual loss• Pattern of bleeding – regular or irregular.• Intermenstrual bleeding.• Amount of blood loss- greater or less than usual
• Number of sanitary towels or tampons used.• Passage of clots or flooding. Pelvic pain – site of pain, nature and relation to periods.• Anything that aggravates or relieve the pain.• Vaginal discharge- amount, colour, odour, presence of blood.• Abdominal mass
•Menstrual cycle• Age of menarche.• Usual duration of each period and length of cycle, amount, dysmenorrhoea• First day of last menstrual period.( L.M.P)• Previous obstetric history• Number of children with ages and birth weights.• Any abnormalities with pregnancy, labour or the puerperium.
Any termination of pregnancy with record of gestation age and any complications• Previous gynaecological history Any previous gynaecological treatments or surgery, date of last cervical smear.
•Sexual and contraceptive history• History of discomfort , pain or bleeding during intercourse.• The use of contraception and type of contraception used.• Previous medical history• Any serious illness or operations with dates• Family history
Enquiry about other systems• Appetite, weight loss, weight gain.• Bowels• Micturation.• Other systems.Social history• Socio-economical status• Smoking, alcohol intake.Drug history
Summary• It is important to summarize the history in one or two sentences before proceeding to examination to alert the examiner to the sailent features.
Examination• Smiles, introduces her/himselfGeneral examination• Anaemia, jaudice• Lymphnode• Thyroid gland• ExtremitiesChestBreasts – particularly relavant if there is a suspected ovarian mass
Abdominal examination• Empty the bladder before abdominal examination• She should be comfortable and lying semi- recumbent, with a sheet covering her from waist down, but the area from the xiphisternum to the symphysis pubis should be left exposed.• It is usual to examine the women from her right- hand side.
Inspection• The contour of the abdomen should be inspected- obvious disension or mass• The presence of surgical scars, dilated veins or striae gravidarum .• It is important specially to examine the umbilicus for laparoscopy scars and just above the symphysis pubis for Pfannenstiel scars (used for Caesarean section, hystrectomy, etc….) , herniae or not
Palpation• First, if the patient has any abdominal pain , she should be asked to point to the site.This area should not be examined until the end of the palpation.Palpation using the right hand is performed, examining the left lower quadrant and proceeding in a total of four steps to the right lower quadrant of the abdomen.
• Examination for masses, liver, spleen and kidneys.• If the patient has pain, palpated gently and look for signs of peritonism, i.e. guarding, rigidity and rebound tenderness.• Inguinal herniae and lymphnodes.
Percussion• Percussion is particularly useful if free fluid is suspected.In the recumbent position, ascitic fluid will settled down into a horseshoes shape and dullness in the flanks can be demonstrated.• As the patient moves over to her side, the dullness will move to her lower most side, this is known as shifting dullness.A fluid thrill can also be elicited.
Ausculation• Bowel sounds, bruit.Pelvic examination• Consent and female chaperone.Privacy.• Needs gloves, speculum, lubricant.• Good light with the patient in the dorsal position, the hips flexed and abducted and the knees flexed.The left lateral position is used for examination of prolapse or to inspect vaginal wall with Sim’s speculum.
• Ask to strain down to enable the detection of any prolapse and also to cough, as this will show the sign of stress incontinence.• A bivalve ( Cusco’s) speculum is inserted to visualize the cervix.
Bimanual digital examination• To use the fingers of right hand in the vagina and to place left hand on the abdomen.• In a virgin or a child , only a PR examination .• Left hand is used to separate the labia minora to expose the vestibule and the examing fingers of the right hands are inserted.
Bimanual examination• Cervix size, position, mobility, consistency ( firm in non-pregnant & soft in pregnant uterus) tenderness ( in ectopic pregnancy )• Uterus position, AV/RV, mobility, size, mass related to uterus, tenderness
• Both culs Adnaxal mass ( ovarian cyst )• POD• Discharge on vaginal examination fingers
• The uterosacral ligaments can be palpated in the posterior fornix- scarred or shortened in endometriosis.Rectal examination• An alternative to VE in a virgin or a child• It may be useful to differentiate between enterocoele and rectocoele.