Example of Gynaecological History and Examination PDF

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Summary

Guide to Medical Students on Gynaecological History and Examination....

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Reproductive Health History and Examination

Gynaecological History Name, age, occupation Presenting problem  Allow patient to describe in own words – important to understand what it is that the patient perceives to be the problem  Further questioning – as much information as possible o e.g. Pain – type, where, when, severity, is it cyclical? o When did problems start? Similar problems in the past? o Associated features relevant to presenting complaint e.g. hot flushes if perimenopausal or hirsutism, hot flushes, galactorrhoea, weight loss if amenorrhoeic o Investigations done, treatment tried Gynae History Menarche/menopause if appropriate LMP – is she certain? Usual menstrual cycle – ? 5/28 – when did it change? Menstrual loss: Days of bleeding, days between onset of bleeding, pattern. Heaviness – type of protection, frequency of changing, clots, flooding, effect on work, is she up at night? Are her periods painful? – If so when in relation to bleeding?  Intermenstrual bleeding  Pain – type, where, when, severity, is it cyclical?  Vaginal discharge – timing in cycle, colour, consistency, is it itchy? Sexual history • ? Sexually active • ? Any problems with intercourse – If relevant how often • ? Painful – dyspareunia – ? deep, ? superficial • Postcoital bleeding Contraceptive history • Current – including asking whether partner has had vasectomy • Previous Smear history • Last smear ? any abnormal smears, ? attended colposcopy, ? treatment to cervix Urinary tract symptoms • Frequency – number of times per day, hours between PU • Nocturia – how many times at night? • Dysuria, haematuria, urgency • Incontinence o stress, urgent: provoking factors, running, laughing, coughing Bowel symptoms – frequency and consistency of bowel movement   

Past Obstetric and Gynae History (POGH)  Previous gynae problems, previous gynae surgery  Previous pregnancies o Number, ? outcome – miscarriages/ectopic/live born o ?CS Past Medical/Surgical history Medication/Allergies – including over the counter medication/remedies Social History  Occupation, family support, accommodation  Smoking/alcohol consumption Family History Systemic enquiry

Gynae Examination General examination – appreciate the need for a chaperone; demonstrate awareness of patient dignity; BMI Abdominal examination • Inspection o Scars, distension, masses palpable – ? arising from the pelvis • Palpation o Masses o Tenderness o Peritonism Pelvic examination Inspection • Vulva o ? healthy, ? abnormalities o ? atrophic Speculum Examination  Cusco speculum, Sims speculum  Vagina o Prolapse o Discharge o Atrophic mucosa  Cervix o Appearance – normal/abnormal o Ectropion  Swabs/smear at this point Bimanual examination • Vaginal – soreness/vaginismus • Cervix o Position, o Consistency, mobility o Tenderness, cervical excitation

• Uterus o Position – anteverted, axial, retroverted o Size – fruit o Tenderness – utero-sacral ligaments o Mobility • Adnexae o Tenderness o Mass, ? separate from uterus Summary of case  Summary of history and examination findings  Differential diagnosis  Investigations  Provisional management plan...