This document outlines the components of a gynecological clinical interview and examination. The interview collects information on the patient's presenting complaint, medical history, menstrual history, obstetric history, sexual activity, and family history. The physical examination includes inspection of external genitalia, speculum examination of the vagina and cervix, and bimanual palpation of the uterus, adnexa, and pouch of Douglas. The findings are then documented. The goal is to obtain a comprehensive history and perform an examination to evaluate any gynecological issues.

1. Gynecological clinical interview
1. Introduction
- Name
- Age
- Married/unmarried
- If married, married duration and
how many children?
- Occupation
- Address
- Date of admission
2. Presenting complaint
- Brief statement of the general
nature and duration of the main
complaint
- (ex- complains of bleeding per
vaginal for 18 days duration)
3. Subsidiary complaints
a. Ex fever for 5 days
4. History of the presenting complaint
- Describe the presenting complaint
in chronological order
- Eg – abnormal menstrual bleeding
 LRMP
 Pattern of bleeding –
regular/irregular
 Amount
 Fresh or altered blood
 Passage of clots or flooding
 No of sanitary towels used
per day
 Intermenstrual bleeding
 Associated symptoms
 Abdominal pain
 Backache
 Dyspareunia(
deep/superficial)
 Features of anemia-
faintishness
 Effects on day today
activities
5. History of subsidiary complaints
- Describe the subsidiary complaint
in chronological order
6. System inquiry
- Appetite,LOW,LOA
- Urinary symptoms
 Frequency –day and night
 Urgency
 Hesitancy
 urge incontinence
 stressincontinence
 retention
- bowel habits
 frequency
 constipation/loose stools
 bloodstained
- CVS
 Shortnessof breath
 Palpitations
- Respiratory symptoms
 Cough
 Haemoptysis
- CNS
 Numbness
 Fits
- Menopausal symptoms
7. Menstrual History
- Age of menarche
- LRMP
- Length and duration of the cycle
- Premenstrual symptoms

2. - Dysmenorrhea
8. Past Gynaecological History
- Symptoms
- Abortions
- Surgery – D&C, PAP smear
- Drug treatment
9. Past Obstetrics History
- No of children with age and birth
weights
- Any abnormalities with pregnancy,
labor, puerperium
- No of miscarriages and gestation,
which they occurred
- (if the blood group is negative
whether the rhogum given or not)
10. Coital History
- Frequency
- Dyspareunia – superficial/deep
- Post coital bleeding – amount – for
how long, fresh/altered
11. Contraceptive History
- Using or not
- Method ( OCP, condoms )
- Duration
- Complications
12. Past Medical History
- HT, DM, BA, IHD
13. Past surgical History
- Operations ( under GA is
important )
14. Dietary History
- Dietary iron intake
- Fat content of a diet
- Amount of food intake
15. Family History
- HT, DM, IHD, carcinomas
associated with genital tract)
- Carcinoma/ polyps in GIT
- Carcinoma of breast
16. Social History
- Occupation of the patient, income
- Occupation of the husband/
income
- Family support
- Is any family member will get
affected due to Pt’s illness?
- Smoking
- Alcohol
Examination
1. General examination
- Comfortable or not
- Well/ ill
- Dyspneoic
- Pale
- Icterus
- Thyroid enlargement
- LN enlargement – inguinal
- Bleeding patches over the skin
- Varicose veins
- Ankle oedema

3. 2. CVS
- Pulse rate
- Blood pressure
- Ht Dr/murmurs
3. Respiratory system
- Respiratory rate
- Breath sounds
- Added sounds ( ronchi,
crepitations )
4. CNS
- Conscious, rational
- Cranial nerves
- Motor system
- Sensory system
5. Abdomen
- Distened/ non distended
- Surgical scars
- Dilated vessels
- Umbilicus
- Hernia
- Diverticulation of recti
- Lump
 Site, size(ex. Compatible
with 16 wks of POA) shape
 Consistency
 Surface
 Margins
 Tenderness
 Moves horizontally and/
vertically
 Can/ can’t get below the
lump
- Liver, spleen
- Free fluid
- Bowel sounds
6. Vaginal examination
Inspection
- Vulva- swelling, soreness, scratch
marks, warts
- Discharge
- Ask to strain and look for lumps
arising at vulva
- Ask to cough and look for
incontinence
Speculum
Vagina
- Lumps, ulceration
- Purulent/ whitish discharge
Cervix
- Size, color
- Surface
- Nodules, growths
- Os
 Nulli/ multiparous
 Discharge, bleeding,
products of conceptus
 Contact bleeding
 Open/close
 Descent

4. Palpation
- Cervix
o Tenderness
o Consistency
o Size
o Growth,nodules
- Os
o Nulli/multiparous
o Discharge,bleeding,products
of conceptus
o Contact bleeding
o Open/close
o Descent
- Uterus
o Size
o Position- ante/retro
o Mobility
o Ante.Surface
o Post.Surface
o Utero sacral ligament
- Adnexiae
o Tenderness
o Tethering
o Lumps
- Pouchof douglas
o deposits
Presentingfindings
There is female typehair distribution. (nothing
called“ normal”hairdistribution.Male type
(inPCOS) or shaven.
Externalgenitalia looksnormal.Vagina is
atrophied.No visible lumps.
Separate the labiabykeepingthe fingersat
upper2/3 & lower1/3 junction.
Urethral& vaginalopeningsarenormal.
Askto cough.
There is no stress incontinence.
Askto strain.
There is cystocele/ rectocele etc.
InsertCusco’sspeculum.
Cervix is nulliparous/multiparous.
Os is closed.
Ant& postlips (in multipara) arenormal/
ulcerated/ectropian.
There is purulentdischarge.
PVE
Os is closed
Cervix is firm.No cervical excitation (optional)
–in PID.
Uterusis ante/retroverted &normal/16
weekssize.
No adenexialmasses.