The gynaecological history and examination pdf

Chapte r 1

The gynaecological history

and examination

History

Examination

Investigations

OVERVIE W

A careful detailed history is essential before the examination of any patient In addition to a good general history, focusing on the

history of the presenting complaint will allow you to customize the examination to elicit the appropriate signs and make an accurate

diagnosis.

When interviewing a patient to obtain her history, the

consultation should ideally be held in a closed room

with no one else present. Enough time should be

allowed for the patient to express herself, and the doc￾tor's manner should be one of interest and under￾standing. It is important that a template is used for

history taking, as this prevents the omission of import￾ant points. A sample template is given on page 2.

Examination

It is important that the examiner smiles, introduces

her/himself by name and, if appropriate, asks the

patient's name. A handshake often helps to put the

patient at ease.

Important information about patients can be

obtained by watching them walk into the examination

room; poor mobility may affect decisions regarding

surgery. While obtaining a history, it is possible to

assess the patient's affect. A history that is taken with

sensitivity will often encourage the patient to reveal

more details that are relevant to future management.

Before proceeding to abdominal examination, a

general examination should be performed. This

includes examining the hands and mucous mem￾branes for evidence of anaemia. The supraclavicular

node should always be examined, particularly on the

left side, where, in cases of abdominal malignancy,

one might palpate the enlarged Virchow's node (this

is also known as Troissier's sign). The thyroid gland

should be palpated.

The chest and breasts should always be examined;

this is particularly relevant if there is a suspected ovarian

mass, as there may be a breast rumour with secondaries

2 The gynaecological history and examination

I Symptoms

History-taking template

The following outline is suggested.

• Name, age, occupation

• A brief statement of the general nature and duration ot

the main complaints.

History ol presenting complaint

This section should focus on the presenting complaint,

But certain important points should always be enquired

about.

• Abnormal menstrual loss.

• Pattern of bleeding - regular or irregular.

• Intermenstrual bleeding.

• Amount of blood loss - greater ot less than usual

• Number of sanitary towels or tampons used.

• Passage of clots or flooding.

• Pelvic pain - site of pain, nature and relation to periods.

• Anything that aggravates or relieves the pain.

• Vaginal discharge - amount, colour, odour, presence

of blood.

Obviously if the presenting complaint is one ot subfertility or

is u re-gynaecological, the history mus! be appropriately

tailored (see Chapters 7 and 16).

Usual menstrual cycle

• Age of menarche

• Usual duration of each period and length of cycle.

• First day ot the last period.

Previous gynaecological history

This section should include any previous gynaecological

treatments or surgery. Trie date of the last cervical smear

should also be recorded.

Previous obstetric history

• Number of children with ages and birth weights.

• Any abnormalities with pregnancy, labour or the puerpenum.

• Number of miscarriages and gestation at which they

occurred.

• Any termination of pregnancy with record of gestation

age and any complications.

Sexual and contraceptive history

• History of discomfort, pain or bleeding during intercourse.

• The use of contraception and type of contraception used.

Previous medical history

• Any serious illnesses or operations with dates.

• Family history.

Enquiry about other systems

• Appetite, weight loss, weight gain

• Bowels.

• Micturition.

• Other systems.

Social history

The history regarding smoking and alcohol intake should be

obtained. It is important to ascertain whether the woman is

married or has a sexual partner Any family problems should

be discussed, and it is especially important in the case of a

frail patient to enquire about home arrangements if surgery

is being considered.

Summary

It is important to summarize the history in one or two

sentences before proceeding to examination to alert the

examiner io the salient features

in the ovaries known a"s Krukenburg tumours. In

addition, a pleural effusion may be elicited as a conse￾quence of abdominal ascites. The next step should be to

proceed to abdominal and pelvic examination.

Abdominal examination

The patient should empty her bladder before the

abdominal examination. She should be comfortable

and lying semi-recumbent, with a sheet covering

her from the waist down, but the area from the

xiphisternum to the symphysis pubis should be left

exposed. It is usual to examine the woman from her

right-hand side. Abdominal examination comprises

inspection, palpation, percussion and, if appropriate,

auscultation.

Inspection

The contour of the abdomen should be inspected and

noted. There may be an obvious distension or mass

(Fig. 1.1).

The presence of surgical scars, dilated veins or

striae gravidarum (stretch marks) should be noted. It

is important specifically to examine the umbilicus for

laparoscopy scars and just above the symphysis pubis