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The gynecological history and examination

Meidcal lecture notes

There is a basic structure for all gynecological histories but this can differ slightly depending on the presenting complaint.

When taking any history in medicine it is essential to understand what the presenting complaint means and what the possible causes (differential diagnosis) of the presenting complaint may be. After all, it is the aetiology of a symptom that guides the physician's questioning.

 

Basic Structure of a Gynecological History

 

Introduction
  • Name of patient
  • Age of patient
  • Consent for questioning

 

Presenting Complaint

 

  • It is important to ask as open a question as possible in this part of the history and to ensure the complaint is understood as everything else follows on from here
 
History of Presenting Complaint

 

This will differ slightly depending on the presenting complaint but follows a vague structure:

  • If pain is involved ascertain site, radiation (if any) and character
  • Onset
  • Periodicity
  • Duration
  • Recurrence?
 
Menstrual History

 

  • Menarche and menopause
  • 1st day of last menstrual period
  • Length of bleeding (days)
  • Frequency
  • Regularity
  • Bleeding between periods
  • Bleeding after intercourse
  • Nature of periods
    • Heavy? (no of sanitary towels )
    • Clots?
    • Flooding?
 
Past Gynecological History

 

  • Gynecological symptoms
  • Gynecological diagnoses
  • Gynecological surgery
  • Abnormal smears

 

Past Obstetric History

 

  • Gravidity and Parity
    • Dates of deliveries
    • Length of pregnancies
    • Induction of labor/Spontaneous
    • Normal Delivery?
    • Weight of babies
    • Sex of babies
    • Complications before, during and after delivery
 
Past Medical History

 

  • Current or past illnesses
  • Hospital admissions
  • Past surgeries

 

Drug History

 

  • Prescribed medications
  • Non-prescribed medications/herbal remedies
  • Recreational drugs
  • Any known drug allergies .

 

Family History

 

  • Medical conditions
  • Gynecological conditions
  • Malignancies
  • consanguinity

 

Social History

 

  • Occupation
  • Support network
  • Smoking
  • Alcohol
  • marital status


Abdominal Examination

 

  • The  patient  should  empty  her  bladder  before  the abdominal examination.
  • The  area  from  the xiphisternum  to  the  symphysis  pubis  should  be  left exposed. 
  • Abdominal  examination  comprises inspection, palpation, percussion and if  appropriate, auscultation.

Inspection

Pfannenstiel  scars  (used  for  Caesarean  section, hysterectomy,  etc.).

The contour of  the abdomen should be inspected and noted. 

  1. obvious  distension  or mass
  2. Surgical  scars
  3. Dilated  veins  or striae gravidarum  (stretch marks )
  4. Examine the umbilicus for laparoscopy scars
  5. Above the symphysis pubis for  Pfannenstiel  scars  (used  for  Caesarean  section, hysterectomy,  etc.). 
  6. Asked  to raise her head or cough and look for any herniae or divarication of  the rectus muscles

 

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. 

Palpation  should  include

  1. examination for masses, liver, spleen and kidneys.
  2. If  a mass  is present but it is possible to palpate below it, (so its a abdominal mass )
  3. the characteristics of a pelvic mass is  that one cannot palpate below it.
  4. If  the patient has pain, her abdomen should be palpated gently and  the examiner should  look for  signs of peritonism,  i.e. guarding and rebound tenderness.
  5. The patient should also be examined for inguinal herniae and lymph nodes.

Percussion

  • In  the  recumbent  position,  ascitic  fluid  will settle down into a horseshoe shape and dullness in the flanks  can be demonstrated.
  • As  the patient moves over  to  her side,  the dullness will  move  to  her  lowermost  side;  this  is  known  as 'shifting dullness'. A fluid  thrill can also be elicited.
  • An enlarged bladder due to urinary retention will also

Auscultation

 

Pelvic examination


the patient's  verbal  consent  should  be  obtained image

female chaperone should be present for any intimate examination.

The  external  genitalia  are  first  inspected  under a  good  light

The  left  lateral  position  is  used  for  examination of  prolapse  or  to  inspect  the  vaginal  wall  with  a Sims'  speculum 

The  patient  is  asked  to strain  down  to  enable  the  detection  of any  prolapse and also  to  cough, as  this will  show the sign of stress incontinence.

After this, a bivalve  (Cusco's)  speculum is  inserted to visualize the cervix

Bimanual  digital  examination  is  then  performed This  technique  requires practice.  It is  customary  to  use  the  fingers  of the  right  hand  in  the
vagina and to place the left hand on the abdomen.  bivalve  (Cusco's)  speculum

  1. The cervix ---> hardness or irregularity noted. T
  2. The  uterus---> size,  shape,  position,  mobility and tenderness ofthe uterus are noted.
  3. Except in a very thin woman, the ovaries and Fallopian tubes are not  palpable. 
  4. The uterosacral  ligaments  can  be  palpated  in  the  posterior  fornix  and may be  scarred or shortened in women with endometriosis.

Rectal  examination


it  may be  useful  to  differentiate  between  enterocele and  rectocele  and  can be used  to  assess  the size  of a
rectocele.

The gynecological history and examination The  gynecological history and  examination Reviewed by Radiology Madeeasy on January 25, 2011 Rating: 5
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