HISTORY AND EXAMINATION OF THE GYNAECOLOGICAL PATIENT

MIKAH S.

DEPT. OBST. & GYNAE.,

BHUTH, JOS CAMPUS.

GENERAL CONSIDERATIONS

• Almost similar to medicine/surgery
• Aim at making a diagnosis and instituting appropriate management
• Involves personal and private issues
• Sensitivity, confidentiality and modesty required
• Respect for culture and patient’s preferences
• Create a good impression
• Patients have individual differences

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GENERAL CONSIDERATIONS

• Systematic pattern preferred
• Courtesy is of utmost importance
• Patient and non-judgmental
• Good knowledge of differentials necessary for a good history

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PATTERN OF HISTORY TAKING

• BIOSOCIAL DATA (Name, Address, Age, marital status, occupation)

*Source of history

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• TOP RIGHT CORNER

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-PARITY (P)

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- LAST CHILD BIRTH

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-LAST MENSTRUAL PERIOD (LMP)

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HISTORY TAKING

• PRESENTING COMPLAINT / Duration

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• HISTORY OF PRESENTING COMPLAINT
• Analysis of the presenting complaint
• Characteristics of the symptoms and other associated complaints
• Previous investigations and treatments
• Relevant history contributory to the diagnosis
• REVIEW OF SYSTEMS

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HISTORY TAKING

• GYNAECOLOGICAL HISTORY

- menstrual history

-contraceptive history

• Previous gynaecological procedures

• PAST OBSTETRIC HISTORY

Total number of pregnancies and their history in chronological order

HISTORY TAKING

• PAST MEDICAL AND SURGICAL HISTORY

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• DRUG HISTORY

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• FAMILY AND SOCIAL HISTORY

-Twins, Diabetes, Hypertension, SCD, Marital status, Alcohol/Drugs, Occupation

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HISTORY TAKING

• SUMMARY

-age, parity, main presenting complaint/duration, any significant information in any segment of the history all in one sentence.

PHYSICAL EXAMINATION OF THE GYNAECOLOGICAL PATIENT

• GENERAL CONSIDERATIONS
• Environmental comfort and privacy
• Sensitivity and non- judgmental
• Chaperone
• Some examinations in gynaecology require skills and techniques
• IPPA Principle still observed

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GENERAL EXAMINATION

• GENERAL EXAMINATION

-Overview of the patients general condition

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• Gait, affect, mental state, height, weight,

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• checking for pallor, jaundice and oedema

SPECIFIC EXAMINATIONS

• THYROID GLAND EXAMINATION – Where endocrine problems are suspected
• BREAST EXAMINATION – Elucidate galactorrhoea and presence of masses
• CARDIOVASCULAR
• CHEST

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SPECIFIC EXAMINATIONS

• ABDOMEN – Exposure should be adequate but not undue
• IPPA

MASS- Site, size, shape, differential warmth, tenderness, consistency, surface, margins, mobility, attachments, origin, percussion

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ABDOMINAL PALPATION

SPECIFIC EXAMINATIONS

• PELVIC EXAMINATION

-Dorsal, lithotomy or Sim’s position

Inspection - vulva, speculum – Cusco’s or Grave’s, Sim’s speculum

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Bimanual examination

-evaluate pelvic organs

• Note size, shape, position, contour, mobility and tenderness of the uterus
• Also palpate the adnexa
• POD
• Cervical motion tenderness

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LITHOTOMY POSITION

BIMANUAL VAGINAL EXAM

BIMANUAL VAGINAL EXAM

SPECIFIC EXAMINATIONS

• Rectal examination

-used in virgins, postmenopausal women and children

- Also in some gynacological conditions

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WHAT I HEAR , I FORGET;

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WHAT I SEE, I REMEMBER;

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WHAT I DO, I UNDERSTAND.

- PROVERB

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THANK YOU!