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HISTORY AND PE IN GYNECOLOGY

4.

Gynecologic Surgical Procedures

Minor and major operations
Endometrial, vulvar, vaginal, cervical biopsies,
laparoscopy, etc
Procedure, diagnoses, complications should be
noted

5.
6.

Urologic History
Pelvic pain
Location, timing, quality, intensity, duration,
radiation
Precipitating & alleviating factors
Vaginal bleeding
Sexual status and Contraceptive use
Age of first sexual contact
No. of sexual partners
Types of relationships
Dyspareunia (pain or discomfort during coitus),
sexual dysfunction (including the partner)

A. GENERAL DATA
Name, age, occupation, marital status, religion
Gravidity no. of pregnancies carried out
Parity no. of pregnancies that have reached the
age of viability (20wks AOG)
B. CHIEF COMPLAINT
Reason for consult
Must be in the patients vernacular
C. HISTORY OF PRESENT ILLNESS/GYNECOLOGIC
PROBLEM
Allow patient to present problem as she sees it
Presented as a chronologic history of the current
problem
Onset, amount, duration, characteristics
Associated signs & symptoms, pain, anemia (due
to profuse bleeding)
o Vaginal discharge
o Dyspareunia (ask if pain is felt on deep
or shallow penetration)
o Abdominal pain
o Abdominal masses location, size,
consistency, mobility, tenderness
1.

2.

3.

Menstrual History
Age of menarche
Duration of each monthly cycle
No. of days during which menses occur
Regularity of menstruation
LMP and PMP
Characteristics of menstrual flow
o Color
o Amount of flow
o Accompanying sx
o Generally, menstruation occurs monthly
(21 40 days), for 4 7 days, bright
red, with cramping on the day preceding
& the 1st day of the period
o Irregular, dark in color, painless, and
frequently
short
or
very
long
menstruation may indicate lack of
ovulation
o Anovulatory cycles: usually seen in first
few
cycles
of
teens
and
in
premenopausal women
Note any vaginal bleeding not related to menses
If postmenopausal, ask the ff: age at last
menses, menopausal sx, postmenopausal
bleeding
Pregnancy History
Year of pregnancy, duration
Type of delivery
Size, sex, current condition of baby
Complications
Breastfed and how long
Elective terminations and spontaneous abortions,
ectopic/molar pregnancies
Father of each pregnancy (to to estimate no. of
sexual partners)
Vaginal and Pelvic Infections
Infection, treatment, complications

7.
8.

D. SIGNIFICANT
HEALTH
PROBLEMS/GENERAL
HEALTH HISTORY/PAST MEDICAL HISTORY
1. Systemic illnesses
2. Medications taken and indications
3. Allergies
4. Evidence of bleeding or clotting problems
5. Smoking amount, length of time she smoked,
attempts at quitting
6. Use of illicit drugs length of time used, types, side
effects
7. Alcohol intake
E.

FAMILY HISTORY
Detailed FH of 1st order relatives -> construct
family tree
Ask about congenital malformations, MR,
pregnancy loss

F.

OCCUPATIONAL AND SOCIAL HISTORY

Spouses jobs held and work performed, hobbies
Social hx: residence, whom she lives with, where
she has travelled

G. SAFETY ISSUES
Use of seatbelts, helmets, appropriate footwear
Intimate partner violence
H. REVIEW OF SYSTEMS

Necessary to uncover symptoms from other

areas that relate to reproduction & gynecologic
problems or other medical conditions

PHYSICAL EXAMINATION
-

Complete PE must be done at the first visit and at

each annual check up
Px will decide if she wants a companion to be present
o But it is preferred if meron
Begins with general evaluation
o Appearance & affect
o Weight, height, BMI
o Vital signs
o EENT
o Thyroid gland (check for goiter or nodules)
o Pulmo exam - IPPA

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o
o

Cardio exam IPA

Breast examination

Examine each breast with px sitting

with arms raised & supine

Attention to entire breast mound

(from midsternum to posterior
axillary line, from costal margin to
the clavicle)

Inspection & palpation to assess:

o Skin flattening, dimpling
o Skin erythema
o Skin edema
o Nipple retraction, eczema,
discharge
o Breast fixation
o Tissue thickening
o Palpable masses

Evaluation
for
axillary
&
supraclavicular lymphadenopathy

Best time to examine: 1 week

after end of menstrual flow

Redness, excoriation, discoloration,

vesicles, warts, pustules, neoplasms
o Skin scars: previous episiotomy or
lacerations
Inspect perineal structures
o Clitoris (normal: 1 1.5cm)
o Labia majora/minora
o Introitus (intact, imperforate, open
hymen)
o Perineal body: focal point of support for
the perineum

Between vagina & rectum

Abdominal Examination
A.

B.

Inspection
o Symmetry, scars, discoloration, striations
(suggest previous pregnancies or adrenal
gland hyperactivity)
o Note female eschucheon
o If diamond shape (similar to males)
indicates excessive androgen
activity
Palpation
o Note for organomegaly and masses
o Fluid wave
o Rigid abdomen (spasm in rectus muscles
secondary to intraabdominal irritation)
o Elicit
rebound
phenomenon
/tenderness
o Gently press on abdomen and
release -> pain under the spot
(direct rebound) or in a different
portion of the abdomen (referred
rebound)

C. Percussion
o Fluid wave vs solid organs & masses
D. Abdominal Auscultation
o Hypoactive or absent bowel sounds: ileus
due to peritoneal irritation of the bowel
o Hyperactive bowel sounds: partial
complete bowel obstruction

Pelvic Examination

Px lying supine with legs in stirrups

Inspection of the External Genitalia

Ensure that bladder is empty (except in urinary

stress incontinence because they cannot be
examined w/ an empty bladder)

Instruct px and explain procedure

Start with mons pubis

o Pattern of hair distribution (as she ages,
hair becomes less dense) and evidence
of lice (pediculosis)

Inspect skin of perineum

Palpation
nd
th

Use 2 and 4 fingers of the gloved hand separate

labia minora
o Inspect urethra and its length milk with
middle finger of other hand

Any pus present -> Gram stain &

culture (frequently gonococci)
o Place index finger in introitus with thumb
outside of the labium

Identify cysts of Bartholins glands

o Note
presence
of
cystocele
or
cystourethrocele in opening of vagina

Bulging upward in posterior wall:

rectocele

Cyst in the cul de sac:

enterocele

These 3 indicate relaxation of the

pelvic supports
Speculum Examination

3
types
of
Graves
speculum:
o Small:
children,
women
who
underwent
tight
perineal repair, aged patient who has
undergone severe involution
o Medium: most women
o Large: obese or grand multiparas

Pederson speculum
o Length of Graves but narrower
o For those not sexually active, never been
pregnant, have not used tampons

Warm the speculum

Insert transverse diameter of speculum in the

anteroposterior position -> introitus -> downward
motion
o Done to avoid causing discomfort to the px
due to the pressure created by the
symphysis pubis

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Insert blades to full length and open so that the

position of cervix may be inspected -> Pap smear
Vagina
o Discharge (check pH)

One drop of vaginal secretion + 1

drop NaCl soln = inspect for
unicellular flagellated protozoa
(Trichomonas vaginalis)

KOH = Candida (mycelium)

o Vaginal epithelial cells: sharp border w/
normal appearing nuclei
Cervix
o Pink, shiny, clear
o Nulliparous: external os is round

Parous: fishmouth appearance

With lacerations: stellate pattern

o Nabothian cysts

Not clinically significant

Formed by metaplasia (columnar ->

squamous)
o Ectropion not clinically significant

Transitional zone seen in areas of

eversion of the external os (due to
scarring after delivery)

Papanicolaou Smear
Basis for Pap smear: exfoliative cytology
Contributed to the decrease in incidence of cervical
CA
Done every 3 years if:
o Low risk individual
o After age 30
o With 3 consecutive negative Pap smears
Do every year if high risk:
o HIV seropositive women
o Immunosuppresed
o (+) DES exposure
o Previously treated for dysplasia or cervical
CA
Pap smear screening may stop at 65 70 y/o
Goal of pap smear: sample exfoliated cells from
endocervical canal & scrape the transitional zone
-

Procedure:
o May use a cotton tipped applicator or Cyto
brush (cyto brush gives more accurate
results & higher yield)

Cytobrush: endocervix

Ayres spatula or any variation:

transitional zone

Other side of spatula: vaginal pool

sample
o Place sample on slide and spray a fixative
solution
Do not use gel as a lubricant, use water instead.
Some notes:
o Yearly chlamydial testing for sexually active
women up to 25 y/o
o Gold std for Chlamydia & gonorrhoea
screening: nucleic acid amplification test
(NMAT)

Performed after pap smear

Bimanual Examination

Dominant hand: Index and middle finger hand

inserted into vagina

Other hand: placed on pxs abdomen above

symphysis pubis

Procedure:
o Uterus pushed up
by pressing on
cervix -> deliver to
abdominal hand
o Identify position,
size,
shape,
consistency,
mobility

Normal size: 6cm x 4cm; weight:

70g

Normally mobile and pear shaped

Firm
2/3 of women: anteflexed uterus (posterior
wall of uterus is palpated by the abdominal
hand)

Some may have retroverted uterus

1st degree: uterus in

straight line with vagina
nd

2
degree:
uterus
backward in the cul de
sac

3rd degree: flexed deeply

into cul de sac,
pressing into rectum (this
type of uterus cannot be
examined bimanually -> do
rectovaginal exam)
Examine adnexa

Ovary: 3cm x 2cm normally

Make this part short because it can

cause a sickening sensation to px

Adnexa not usually palpable in

postmenopausal women due to
involution and retraction of ovary
higher

Rectovaginal Exam

After bimanual exam, do this

by relubricating middle finger
and inserting it into the rectum

Allows palpation of recto

vaginal septum

Thickening or beadiness of
any
of
the
structures:
inflammatory or endometriosis

Exam used in severely

retroverted uteruses
Rectal Exam

Palpate all dimensions with rectal finger

Done due to high incidence of bowel cancer in

women, esp >50 y/o

Note anal sphincteric tone, masses, hemorrhoids,

fissures

May be used in young virgins

SUMMARY:

Rectal exam: young virgins

Internal examination: px with sexual contact

Rectovaginal exam: retroverted uterus

o Conditions in posterior aspect
o Endometriosis, ovarian tumors
Sources:
th
Comprehensive Gynecology (Katz, Lentz, et al) 6 ed