There is a basic structure for all gynecological histories but this can differ slightly depending on the presenting complaint. When taki...
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
The contour of the abdomen should be inspected and noted.
- obvious distension or mass
- Surgical scars
- Dilated veins or striae gravidarum (stretch marks )
- Examine the umbilicus for laparoscopy scars
- Above the symphysis pubis for Pfannenstiel scars (used for Caesarean section, hysterectomy, etc.).
- 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
- examination for masses, liver, spleen and kidneys.
- If a mass is present but it is possible to palpate below it, (so its a abdominal mass )
- the characteristics of a pelvic mass is that one cannot palpate below it.
- 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.
- 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
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.
- The cervix ---> hardness or irregularity noted. T
- The uterus---> size, shape, position, mobility and tenderness ofthe uterus are noted.
- Except in a very thin woman, the ovaries and Fallopian tubes are not palpable.
- 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.
