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History taking:

 Personal data: age, marital, okupasi


 Current problem: actual problem, onset&duration, relateion to mens cycle, previous
treatment
 Micturition: inkontinesia, nokturia, oliguri, makrohematuri, disuri, hesitansi
 Bowel habit: konstipasi, diare, bloating, flatulen
 Mens history: age menarche, durasi bleeding, dismenore, amount bleeding, spotting, post
koital bleeding
 Past obstet history:paritas, number alive child, mode delivery, komplikasi, history
miscarriage, abortus, infertil, previous and actual kontrasepsi
 Past ginekologi history: history STI (abnormal discharge, lower abdominal pain, genital ulcer),
previous abdominal and vaginal operation, nipple discharge
 Sex history: current relationship, number previous partner, dispareuni, sex trauma
 Medical history: previous med condition, ever tested HIV? Nikotin and alkohol intake? Aktual
medikasi?
 Fam history: got sick or died with HT, DM, trombo emboli, Ca breast, ovari, bowel, prostat

Examination:

Always explain to patient what you will do and why

 Equipment needed:
ginek chair, washing basin & soap, light source, clean specula, clean gloves, lubrikan,
mikroskkop dengan 40x pembesaran, slide, swab, sodium dan potasium klorat
Tambahan: disecting forcep, sponge-holding forcep, cervical biopsi forcep, vaginal pack, MVA
kits, bladder kateter, lugols solution, sitobrush, agent fixation
 Privacy:
no one can enter room without permission, lock the door, sign of no entry without
permission, explain what you are goin to do so she can prepare herself cause this could be
very painful, you should respect her fears and embrassment, empathy and respect, use her
own shawl or cloth to cover. If you are male provider, should have one other female.
 General examination:
look at nutriotional status, temperature, pulse and blood pressure to detect in need of
emergency treatment
 Abdominal palpation:
ask to empty the bladder and lie down, inspect for surgical scar, abdominal distention (gas,
ascites) or visible tumor, you can ausculate if you suspect the bowel obstruction, percuss all
four quadran for dullness, tympany, shifting dullness, feel pain or not, palpate the area below
umbilikus softly as deep as the patient allows you, if there are any area where deep
palpation is not possible due to pain. Try to figure out the location, and whether its mobile or
not, assess the size, mobility, and konsistensi.
 Inspection of the vulva:
Before start speculum exam, you should look for: normal development of genital externa,
skin lesion, hirsutisme, scar, discharge, swelling, prolaps
Speculum exam: discuss the patient whether she has already has sex intercourse, you should
not doing speculum if the patient is a virgin. Posisi litotomi, the bladder should be empty.
Ada dua tipe spekulum: bivalve more handy and dont need asisstant, and ante and poste
wall speculum. Use larger for multipara, spekulum should be warm and lubricated

How to insert bivalve spekulum:


Wear clean gloves, direct loght, separate the labia minor with two fingers, insert closed
speculum, if you need more space push the perineum down gently, rotate so the valves
become horizontal, if you insert the spuculum too far you might enter the posterior fornix
behind the cervix and load the cervix up on youar anterior valve, for removal close the valves
a bit but not completely

How to insert ante and poste wall speculum:


First, insert the poste valve and rotate it, insert ante valve and rotate it upwards while
inserting?

Identify the cervix and asses its color, smoothness and shine, any disruption of the surface?
Any reddishness or whitishness? Any discharge or pus? Specifically look for the polip, tumor,
ulcerations, condyloma, IUD threat, squamocolumnar junction. Inspect the vaginal wall for
tumor, ulcerration, change of color, discharge and fistula. Take swab for wet mount and IVA.

Wet mount: take some discharge from the posterior vaginal fornix. Put it on microscope
slide. Add one or two drops of normal saline and put cover slide on top. Use magnification
10x first and identify the polygonal vaginal epithelium cells. Turn to 40 and examine closely.
A normal weet mount shows the epitelium cells, leukocytes and lactobacilli.
Abnormal findings:
- Clue cell: epithelial cells with bacterial overgrowth, it indicate vaginal imbalance called
bacterial vaginosis
- Trichomonas, larger than bacteria, can be identified through their movement in between
the epithelial cell
- Sperm cell
- Yeast, can be demonstrated by adding one or two drops of potassium hydroxid

Bimanual vaginal palpation

Asses the pelvic organ and any abnormal mass between you right hand internally in the
vagina and your left externally on the lower abdomen, patient should be in lithotomy, explain
what you are planning t do

How to do: insert index and middle finger of right hand in the vagina, avoid touching the
external urethral orifici and use jelly or water to avoid friction. Place the left hand on the
lower abdomen above the symphsis and palpate with your finger.

1. Cervix
- Excitation tenderness: move cervix gently to each side with one finger, pain point at tubo
ovarian mass (ectopic, abcess) or inflammation
- Consistency, normal firm pregnancy become softer, cervical cancer can be hard with
iregular surface
- Mobility: put your left hand above the uterus and try to move the cervix against with
your right hand, imobility=cervix ca
- External os open in multipara and miscarriage
2. Uterus
- Axis: ante or retroversi, if you palpate in the anterior fornix ante, if you palpate in the
posterior fornix retro.
- Size
- Consistency: soft, uterine fibroid are hard, advance uterine or cervical malignancy is
often hard but endometrium carcinoma can show as soften enlarged uterus, a large
tuboovarian mass can be mistaken for an enlarged uterus, diff by moving it and asess
cervix moving juga atau tidak.
3. Adnexa, asess the tubo ovarian area by placing your finger in the lateral vaginal fornice
on the right and left side of the cervix and the left on the right or left of middle simfisis.
- Size, normaly ovary not palpable unless very slim premenopausal, diameter 2 cm firm,
normal tubes are not palpable not even in very slim. Jika palpasi bisa, gak tau dari mana
disebut tuboovarian mass, bisa kista ovari, tumor padat, malignan ovary, hidrosalping,
ke, abses
- Tendernes: nyeri pada PID adnexitis, pregnan ektopik, hidrosalping
- Mobility: uterin mass move with the cervix, abses tubo or pid imobile, tumor jin ov
sangat mobil

rectovaginal examination

in cases with suspect malignancy, endometriosis or any process located in the pouch of
douglas. Leave right index finger in the vagina and right middle finger in the rectum, use jelly
to lubricate. Keep the left hand on the abdomen above the symphisis. Feel for the
smoothness and regularity of the surfcae. A disruption of the surface, tumor, ulceration can
be a malignancy or endometriosis penetrating the rectum from the pouch of douglas. Gently
pressing index and middle finger can asess the tissue between rectum and vagina. Induration
or enlargemnet of this area can be endometriosis or cervical/uterine or rectal malignancy.
Asses the broad ligament by gently pushing your two finger upwards against your left hand.
Palpate for induration and enlargemnet . this point to advanced stage cerrvical or uterine
malignancy.

Examination of the breast

It is best to perform a breast palpation in the first week of the cycle as the hormone level is
lowest and thus the breast tissue softest.

1. Inspection, put her hands on her hips and look straight ahead
- Symmetry
- Location
- Visible tumors, with or without ulceration
- Skin changes (redness, orange skin phenomenon) puerperal or non mastitits or inflam ca
- Skin reaction
2. Lymph node palpation
Cervical, supraclavicular, infraclavicular, axillar, parasternal. Palpate with your index and
middle finger. Asess for: size 0,5 -1 cm enlarged in acute or cronic infection malignan,
consistency soft to elastic, mobility imo malignan, tenderness painful infection or trauma
painless metas
3. Breast palpation
Lay down on her back with both hands folded behind her head. Inspect the breast again,
always start with the right breast. Divide the breast in four parts and asess each of the
following parts: upper outer, upper inner, lower outer, lower inner.
Palpate from cranial to caudal or concentric from periphery to the center. Finish by
palpating the areola and check for nipple discharge by milking out the areola and the
nipple. Be ready to take a smear for cytological and microbiological investigation.
Assess: location, size, consistency kist sot and elastic with regular surface, fam hard or
firm well diff reg surface ca hard/firm iregular diff diff, mobility benign mobil, skin
retraction infiltration of carcinoma, skin rashes inflam carcinoma.
4.