GYNECOLOGY
Helen B. Albano, MD, FPOGS
Medical History
The quality of the medical care provided by the
physician
Type of relationship between physician and the
patient
o Can be determined largely the depth of
gynecological history
Patient-Doctor Relationship
o Complete history
o Complete PE
o Labs
New Patient
o Take Time
Obtain comprehensive history
Perform comprehensive PE
o Establish data base, along with DPR basd on
a good communication
Old Patient or the established patient
o Updates
Gynecological changes
Pregnancy history
Additional surgery, accidents or new
medications
History Taking
Overview
o Most important part of gynecological
evaluation
o Provides tentative diagnosis (impression)
before PE
o LEGAL document
Subject to subpoena, may be
defended in court
General Data
Name
Age
Gravidity (G)
o State of being pregnant
Parity (P)
o Outcome of pregnancy
o FPAL (in digits)
F = number of full term pregnancy
P = number of preterm pregnancy
A = Abortion
L = total number of living children
o Ex: G1P0 0001
LMP (Last Menstrual Period)
o Also take the first and last day of normal
menstruation
PNMP (Previous Normal Menstrual Period)
EDC/EDD and AOG – Expected Date of
Confinement/Delivery
o Nigella’s EDC
3 mos back + 7 + 1year ???
o AOG (wks of gestation)
Date and Time of Consultation/Admission
Chief Complaint
Only one
Reason for admission
Common gynecological complaints
o Bleeding (vaginal)
o Pain (specify: use 9 regions of abdomen)
o Mass (abdominal or pelvic)
o Vaginal discharge
o Urinary or GI symptoms
o Protrusion out of the vagina
o Infertility
HPI (History of Present Illness)
Refers to the chief complaint
o Duration
o Severity
o Precipitating factors
o Occurrence in relation to other events
Menstrual cycle
Voiding
Bowel movements
History of similar symptoms
Outcome of previous therapies
Impact on the patient’s:
o Quality of life
o Self-image
o Relationship with the family (sexual history
to husband)
o Daily activities
Menstrual History
Age of menarche
Date of onset of menstrual periods
Duration and quantity (i.e. number of pads used per
day) of flow
Degree of Discomfort
Premenstrual symptoms
Cycle
o Counted from the first day of menstrual flow
of one cycle to the first day of menstrual
flow of the next
Range of normal is wide
o Normal range of ovulatory cycles
Between 21 & 35 days
o 28-day cycle represent the median cycle
o A recent change in the usual pattern maybe
a more reliable sign of a problem
Average menstrual blood loss
o 30 ml (entire)
o 10-80 ml (normal range)
Excessive menses
o Need to frequently change saturated
sanitary pads or tampons
o Passage of many or large blood clots
Dysmenorrhea
o Painful menstruation
o Discomfort or pain at the hypogastric area,
often associated with backache
o Common
o Begins just before or soon after the onset of
bleeding
o Subsides by day 2 or 3 of flow
o May be associated with systemic symptoms
Obstetric History
Number of pregnancies
FPAL
Complications of previous pregnancies
o Antepartum, intrapartum or postpartum
Duration of labor
Type of delivery
o Place: hospital, house, hilot, TBA, physician
Anesthesia used
Perinatal status of fetus
o Birthweight
o Early growth and development of children
including feeding habits, growth, overall
well-being, current status
History of Infertility
o Evaluation, diagnosis, treatment, outcome
Medical History
Allergies
Past and current medical and surgical problems
Previous hospitalizations
o Reason, date, outcome
Vaccination
o Type, date
Surgical History
Operative procedure
o Outcomes
o Complications
o Surgical diagnosis
o Pathologic diagnosis
Review of Systems (subjective)
Pulmonary
Cardiovascular
Gastrointestinal
Genital
Urinary
o Don’t combine, as in GU
Vascular
Neurologic
Endocrinologic
Immunologic
Breast Symptoms
Masses
Galactorrhea
Pain
Family history
Social History
Marital status
o Number of years married
o Period of infertility
Drug (causes abruption placenta), alcohol use,
smoking
Occupational History
o Exposure to radiation
o Infectious agents
Sexual History
o Partners, protection from STDs
Emotional or sexual abuse
Family History
Significant medical and surgical disorders that runs
in the family
Heredofamilial diseases
Evaluation of the General Appearance
General Impression
o Level of consciousness
o Ambulatory
o Nutritional state
o Presence of facial or excessive body hair
o Vital signs
Physical Examination (PE)
(objective)
Follows IPPA (with exception of certain organs)
Head and Neck
Chest and Lungs
Heart
Breast
Abdomen
Lower extremities
Pelvic examination
Gynecological Examination
Pelvic Examination
o Most commonly performed medical
procedure
o Performed during the first visit
o Patient should be encouraged to give
feedback during PE to reduce anxiety
o Lithotomy position
Patient lying on her back with both
knees flexed
Buttocks are positioned at the edge
of the table
The feet are supported by stirrups
o The patient should empty her bladder just
before the examination
Pelvic Examination consist of:
o Inspection
Visual inspection of the vulva
Speculum examination – vagina and
cervix
o Palpation
Bimanual pelvic examination
o Lithotomy position to allow adequate
exposure
o She should be comfortable and properly
draped
o Should not be painful except in:
Virgins and has not used tampons
for menstrual protection
In women with inflammatory
processes
Menopausic nulligravid
Inspection of the Vulva
o The vulva should be examined for:
General state of hygiene
Growth of hair
Regions of ulceration and rash
Discoloration
Labial abnormality
Excessive vaginal discharge
Lochia – discharged after
delivery
Evidence of perineal trauma from
previous deliveries
Evidence of rectal disease –
hemorrhoids
Bartholin’s and Skeene’s glands can
be inspected and palpated
Presence of ectovaginal fistula or
prolapsed
Guidelines in Daily Pelvic Examination
Warning
o The physician should prepare the patient for
any pelvic examination by warning her in
advance and examining fingers and
speculum
Important:
o Not only because the patient cannot see
what is going on
o But also because the area to be examined is
extremely sensitive, both psychologically
and physically
Inspection of the Vagina and Cervix
Grave’s Speculum
o Employed for visualization of the vagina and
cervix
o Bivalve
Anterior valve shorter than the
posterior valve
Speculum Examination
Techniques that should be remembered in speculum
exam
If for pap smear, the speculum
should be warmed, either by a
warming device or placing in warm
water, if and then it should be
lubricated
By spreading the labia and placing
some tension on the posterior
fourchet, the speculum can be
gently inserted at an angle of about
45O to avoid the urethra
o Speculum insertion
Placing the tranverse diameter of
the blades in the anteroposterior
position and guding the blades
through the introitus in a downward
motion with the tips pointing toward
the rectum
The anterior wall of the vagina is
backed by the pubic symphysis,
upward pressure causes patient
discomfort.
In the resting state, the vagina lies
on the rectum and actually extends
to the rectum
The speculum should be turned so
that the transverse axis of the
blades is in transverse axis of the
vagina
It should now lie inferior to the
cervix
With gentle opening of the
speculum, the valves separate and
the cervix can be visualized
The blades should be inserted to
their full length
The cervix is inspected next
It should be pink, shiny and clear
Nulliparous – external os should be
round
Parous – external os takes on a
fishmouth appearance
With previous cervical
lacerations, healed stellate
laceration may be found
Inspection
o The cervix should be inspected for
Color
Erosion
Degree of discharge (leucorrhea –
discharges other than blood)
Evidence of trauma
Presence of lesion
*Pap smear is encouraged if not done yet
Pap Smear
Major objectives:
1. sample exfoliated cells from the
endocervical canal
2. Scrape the transitional zone
A collection of cells from the posterior fornix
(maturation index)
Bimanual Pelvic Exam
After the speculum has been….
It is helpful to place a stool at the base of the
examining table and support the examining arm and
elbow during the examination
o This support of the elbow allows greater
sensitivity in the examining fingers
At the same time, a second dimension is added by
employing the other hand to pressure the abdomen
One hould rquire proficiency with the index and
middle fingers of one hand and then always use that
hand for the vaginal examination as the:
1. Vaginal hand (non-dominant hand)
2. The other as an abdominal hand (dominant
hand)
Palpation by Bimanual Examination
Basically allows the physician to palpate the uterus
and the adnexa
The lubricated index and middle fingers of the
dominant hand are placed within the vagina, and
the thumb is folded under
o So as not to cause the patient distress in the
area of the mons pubis, clitoris and pubic
symphysis
The fingers are inserted deeply into the vagina so
that they rest beneath the cervix in the posterior
fornix
The physician should be in a comfortable position,
generally with the leg on the side of the vaginal
examining hand on a table lift and the elbow of that
arm resting on the knee.
The opposite hand is in the patient’s abdomen
above the pubic symphysis
The first palpable… is the cervix
Next is the anteriorly displaced uterus
The flat of the fingers are used for palpation
The uterus is then elevated by pressing up on the
cervix and delivers the uterus to the abdominal
hand so that the uterus may be placed placed
between the two hands
o Identify position, size , shape, consistency
and mobility
The shape of the uterus shuld be described in detail.
The consistency of the uterus is generally firm but
not rock-hard
Any underlying tenderness
o May imply an inflammatory process
Examination of the adnexa
If the right hand is the pelvic hand, the first two
fingers of the right hand are then moved into the
right vaginal fornix as deeply as they can be
inserted
Cervical and adnexal tenderness:
o Ectopic pregnancy
o PID/Salphigitis
o Endometriosis
A normal ovary is approximately 3 cm b 2 cm (about
the size of a walnut) and will sweep between the
two fingers with ease unless it is fixed in an
abnormal position by adhesions.
When the adnexa is palpated, its size, mobility and
consistency must be determined
Adnexa are usually not palpable in postmenopausal
women
If palpable adnexa in menopause may need further
investigation for ovarian pathology, if enlarged
Rectovaginal Examination (read book… its beyond my
powers…)
Confirm bimanual examination
Hemorrh
Should be employed in all patients
After…
o Uterosacral ligament
Any thickening or beadiness
(endometriosis/inflammation)
If the uterus is retroverted
Summary (inspection and palpation only)
o
o
Vagina
o Leukorrhea