GYN 9

• Clinical examination


  Thorough and meticulous, including in-depth history taking and examinations—general, abdominal and internal
• Meticulous history taking alone can give a positive diagnosis in majority of cases without any physical examination
• Examination should proceed with the provisional diagnosis in mind
• Ancillary aids are required to confirm the diagnosis on occasion
• Name

  Information to be obtained during history taking
• Age

  Information to be obtained during history taking
• Address


  Information to be obtained during history taking
• Marital status

  Information to be obtained during history taking
• Parity

  Information to be obtained during history taking
• Social status


  Information to be obtained during history taking
• Chief complaint

  Information to be obtained during history taking
• Patient should be given a hearing about the complaints made in their own words
• Pertinent questions (open-ended or specific) may be asked tactfully and judiciously to substantiate the guess made out of the patient's complaints
• Looking at the patient with eye to eye contact (direct observation) before speaking may give many clues (nonverbal) to the diagnosis, e.g. fear, sadness, apathy or anger
• If multiple symptoms are present, their chronologic appearances are to be noted
• Integration of the symptomatology to one pathology is to be tried first before embarking on the diagnosis of multiple pathology
• Enquiry should be made about the bowel habits and urinary trouble, if any
• Menstrual history enquiries

  • Age of onset of the first period (menarche)
  • Regularity of the cycle
  • Duration of period
  • Length of the cycle
  • Amount of bleeding—excess is indicated by the passage of clots or number of pads used
  • First day of the last menstrual period (LMP)
• Menstrual history representation

  13/4/28, representing that the onset of period was at the age of 13, bleeding lasts for 4 days and occurs every 28 days
• Past medical history enquiries

  • Relevant medical disorders—systemic, metabolic or endocrinal (diabetes, hypertension, hepatitis)
  • Sexually transmitted diseases
• Family history is of occasional value, as malignancy of the breast, colon, ovary or endometrium is often related
• Obstetric history details to be enquired

  • Date
  • Year and events
  • Pregnancy events
  • Labor delivery
  • Method of delivery
  • Puerperium (Baby weight and sex. Birth asphyxia. Duration of breastfeeding, contraception)
• Examination components


  • General and Systemic Examination
  • Gynecological Examination (Breast Examination, Abdominal Examination, Pelvic Examination, Vaginal Examination, Rectal Examination, Rectovaginal Examination)
  • Diagnostic Procedures (Blood Values, Urine, Cervical and Vaginal Smear for Exfoliative Cytology, Examination of Cervical Mucus, Colposcopy, Endometrial Sampling, Culdocentesis)
• General and systemic examination

  Thorough and meticulous, including built, nutrition, stature, body mass index (BMI), pallor, jaundice, lymph nodes, edema of legs, teeth, gums and tonsils, neck, cardiovascular and respiratory systems, pulse, blood pressure
• Breast examination


  • Self-breast examination (SBE) by the patient, Clinical breast examination (CBE) by a skilled professional including visual inspection combined with palpation of the breasts and axilla
• Abdominal examination prerequisites


  Bladder should be empty, patient lies flat on the table with thighs slightly flexed and abducted, physician stands on the right side, presence of a chaperone
• Abdominal examination steps


  • Inspection
  • Percussion
  • Palpation
  • Auscultation
• Pelvic examination


  Includes inspection of the external genitalia, vaginal examination (inspection using a speculum, palpation of the vagina and vaginal cervix by digital examination, bimanual examination of the pelvic organs), rectal examination, rectovaginal examination
• Pelvic examination prerequisites

  • Patient's bladder must be empty, female attendant present, consent required for minor or unmarried, lower bowel empty, light source available, sterile gloves, sterile lubricant, speculum, sponge holding forceps and swabs required
• Patient position for pelvic examination

  Commonly in dorsal position with knees flexed and thighs abducted, physician stands on the right side
• t's bladder must be empty—the exception being a case of stress incontinence
• A female attendant (nurse or relative of the patient) should be present by her side
• To examine a minor or unmarried, a consent from the parent or guardian is required
• Lower bowel (rectum and pelvic colon) should preferably be empty
• A light source should be available
• Equipment required

  • Sterile gloves
  • Sterile lubricant (preferably colorless without any antiseptics)
  • Speculum
  • Sponge holding forceps
  • Swabs
• Position of the Patient

  • Commonly examined in dorsal position with the knees flexed and thighs abducted
  • Physician usually stands on the right side
  • Gives better view of the external genitalia and the bimanual pelvic examination can be effectively performed
• Alternative patient positions

  • Lateral or Sims' position ideal for inspecting any lesion in anterior vaginal wall
  • Lithotomy position (patient lying supine with her legs on stirups) ideal for examination under anesthesia
• Inspection of the Vulva

  1. Note any anatomical abnormality starting from the pubic hair, clitoris, labia and perineum

  2. Note any palpable pathology over the areas

  3. Note the character of the visible vaginal discharge, if any

  4. Separate the labia using fingers of the left hand to note external urethral meatus, visible openings of the Bartholin's ducts and character of the hymen

  5. Ask the patient to strain to elicit stress incontinence or genital prolapse

  6. Look for hemorrhoids, anal fissure, anal fistula or perineal tear
• Speculum examination


  Should preferably be done prior to bimanual examination