Women: brief clinical assessment summary

1. Communication and preparation

• Ensure privacy, dignity and confidentiality.
• Explain why sensitive questions or an intimate examination may be needed.
• Obtain informed consent before examination.
• Offer a chaperone and document whether one was present or declined.
• Use neutral, non-judgemental language; do not make assumptions about sexual orientation, contraception, pregnancy wishes or gender identity.

2. History taking

• Age at menarche, last menstrual period (LMP), cycle frequency, duration and amount of bleeding.
• Dysmenorrhoea, intermenstrual bleeding, postcoital bleeding, abnormal vaginal discharge.
• Menopausal status and postmenopausal bleeding.

• Number of pregnancies and outcomes: gravida and para.
• Miscarriages, ectopic pregnancy, abortions, stillbirths and living children.
• Complications such as hypertension, diabetes, haemorrhage, preterm birth or Caesarean delivery.
• In a woman of reproductive age, always consider and sensitively ask about possible pregnancy.

• Previous gynaecological disease, surgery, cervical screening results and sexually transmitted infections.
• Sexual activity, dyspareunia, contraception, fertility concerns and sexual safety, only when clinically relevant.
• Ask about coercion, intimate-partner violence or safeguarding concerns in a private setting when indicated.

• Contraception and hormone treatment.
• Drugs that could harm a fetus if pregnancy is possible.
• Family history of breast, ovarian, endometrial and colorectal cancer.
• Smoking, alcohol, weight, diet and exercise.

3. General examination

• General appearance, body mass index, blood pressure, pallor, oedema, hirsutism, acne, thyroid enlargement and signs of endocrine disease.
• Examine relevant systems according to symptoms, for example cardiovascular, abdominal, neurological or musculoskeletal systems.

4. Breast examination

• Inspect both breasts and nipples for asymmetry, skin tethering, redness, ulceration, nipple inversion or discharge.
• Palpate all breast quadrants, the nipple-areolar area and axillary/supraclavicular lymph nodes.
• Any new lump, persistent unilateral nipple discharge, skin change or nipple distortion needs further assessment.

5. Abdominal and pelvic examination

• Abdominal examination: inspect and palpate for tenderness, masses, ascites or an enlarged uterus.
• External genital inspection: look for inflammation, ulcers, lesions, discharge or prolapse when relevant.
• Speculum examination: assesses vagina and cervix, allows swabs or cervical screening where appropriate.
• Bimanual examination: assesses uterine size, position and tenderness, plus adnexal masses or cervical excitation tenderness.

6. Important warning symptoms

• Pregnancy with abdominal pain or vaginal bleeding, particularly to exclude ectopic pregnancy.
• Postmenopausal bleeding.
• Heavy bleeding causing dizziness, syncope or anaemia symptoms.
• Pelvic pain with fever or abnormal discharge.
• A new breast lump or suspicious nipple/skin change.
• Abdominal distension, early satiety or persistent pelvic symptoms that could suggest ovarian pathology.

Key message

Examination of a woman: detailed clinical approach

1. Before starting

A. Check indication

• Pelvic or lower abdominal pain
• Abnormal vaginal bleeding
• Vaginal discharge, itching or sores
• Urinary incontinence or prolapse symptoms
• Suspected pregnancy complication
• Infertility assessment
• Cervical screening or a suspected cervical lesion

B. Ensure dignity, consent and safety

1. Introduce yourself and confirm the patient's identity.
2. Explain the purpose and steps of the examination in understandable language.
3. Obtain verbal consent before each part, especially before an intimate examination.
4. Offer a trained chaperone and document their name and role.
5. Ask whether previous examinations were painful, distressing, or associated with trauma.
6. Provide privacy for undressing and appropriate covering with a sheet.
7. Tell the patient that she may ask to pause or stop at any time.
8. Wash hands, prepare equipment, and use gloves for pelvic examination.

2. General physical examination

Observe for

• General appearance: pain, distress, pallor, dehydration.
• Nutritional state and body habitus.
• Height, weight, BMI and blood pressure when relevant.
• Anaemia: conjunctival or palmar pallor.
• Oedema.
• Signs of endocrine disease:
  • Hirsutism, acne or virilisation in androgen excess.
  • Thyroid enlargement or eye signs in thyroid disease.
  • Galactorrhoea if hyperprolactinaemia is suspected.
• Bruising or injuries if there are safeguarding concerns.

3. Breast examination

A. Position

• Patient initially sits upright with arms relaxed by the sides.
• Then ask her to raise both arms above the head.
• Ask her to press hands on hips or press palms together to contract pectoral muscles, which may reveal subtle skin tethering.

B. Inspection

• Symmetry and size
• Skin dimpling or tethering
• Redness, warmth, peau d’orange
• Scars
• Visible lump or swelling
• Nipple retraction or inversion
• Nipple eczema, ulceration or discharge

C. Palpation

• Examine each breast systematically, covering all quadrants including the axillary tail.
• Use the finger pads in a circular or vertical-strip pattern.
• Note any lump’s:
  • Site
  • Size
  • Shape
  • Surface
  • Consistency
  • Mobility or fixation
  • Tenderness
  • Relationship to skin, nipple and chest wall

D. Lymph nodes

• Axillary nodes: central, anterior, posterior, lateral and apical groups
• Supraclavicular and infraclavicular nodes if malignancy is suspected

E. Nipple discharge

• Unilateral or bilateral
• Single duct or multiple ducts
• Colour: bloody, serous, milky or purulent
• Spontaneous or only expressed

4. Abdominal examination

A. Inspection

• Distension
• Scars
• Striae
• Dilated veins
• Umbilical changes
• Visible masses
• Hernias
• Fetal movements or uterine enlargement in pregnancy

B. Palpation

• Superficial palpation for tenderness, guarding or rigidity
• Deep palpation for masses
• Assess a pelvic mass for size, surface, consistency, mobility and tenderness
• Palpate liver and spleen if indicated
• Check for suprapubic tenderness or bladder distension

C. Percussion and auscultation

• Percuss for ascites if abdominal enlargement is present.
• Auscultate bowel sounds when indicated.
• In pregnancy, fetal heart assessment is performed with appropriate obstetric technique, according to gestation and setting.

5. Pelvic examination

1. External genital inspection
2. Speculum examination
3. Bimanual vaginal examination
4. Rectovaginal examination, only if indicated

A. External inspection

• Mons pubis
• Labia majora and minora
• Clitoris
• Urethral opening
• Vaginal introitus
• Perineum
• Perianal area when needed

• Redness, swelling or excoriation
• Ulcers, vesicles, warts or other lesions
• Skin colour changes
• Scars, including previous episiotomy scars
• Discharge, bleeding or offensive odour
• Urethral caruncle or prolapse
• Bartholin gland swelling
• Pelvic organ prolapse

• Anterior vaginal wall bulge: cystocele
• Posterior vaginal wall bulge: rectocele or enterocele
• Uterine or vault prolapse

B. Speculum examination

Technique

1. Explain that pressure may be felt but it should not be painful.
2. Select an appropriately sized speculum.
3. Warm it with water. Lubrication may be used sparingly unless it may interfere with a planned test.
4. With the blades closed, introduce it gently along the posterior vaginal wall.
5. Open the blades slowly until the cervix is seen.
6. Adjust gently to inspect the vaginal walls and cervix.
7. Take required swabs or cervical screening samples.
8. Withdraw the speculum slowly while inspecting the vaginal walls.

Observe the vagina for

• Inflammation or atrophy
• Discharge: amount, colour, consistency and odour
• Bleeding
• Ulcers, lesions, trauma or foreign body
• Masses or prolapse

Observe the cervix for

• Position and appearance
• Ectropion
• Erosion, ulceration, polyp or growth
• Contact bleeding
• Discharge from the cervical os
• Appearance of the external os, for example nulliparous versus multiparous

• High vaginal swab
• Endocervical swab
• NAAT sample for chlamydia/gonorrhoea
• Cervical screening sample, when due and appropriate

C. Bimanual vaginal examination

Technique

1. Lubricate one or two examining fingers, depending on the patient’s comfort and anatomy.
2. Insert fingers gently into the vagina, directed posteriorly.
3. Palpate the vaginal walls, cervix and fornices.
4. Place the other hand on the lower abdomen.
5. Use both hands together to assess the uterus and adnexa.

Assess the cervix

• Position: anterior, central or posterior
• Consistency
• Surface irregularity
• Tenderness
• Cervical excitation tenderness: pain when the cervix is moved. This may occur in pelvic inflammatory disease, but should always be interpreted with the whole clinical picture.

Assess the uterus

• Position: anteverted, anteflexed, retroverted
• Size
• Shape
• Consistency
• Mobility
• Tenderness

• A bulky, irregular uterus may suggest fibroids.
• A uniformly enlarged, soft uterus may occur in pregnancy.
• A fixed or tender uterus may suggest endometriosis, infection or pelvic adhesions.

Assess the adnexa

• Vaginal fingers in the lateral fornix
• Abdominal hand in the corresponding iliac fossa

• Adnexal mass
• Tenderness
• Fullness
• Fixation

Assess the pouch of Douglas

• Tenderness
• Nodularity
• Mass
• Fullness

D. Rectovaginal examination

• Posterior pelvic mass
• Endometriosis
• Rectovaginal septal lesions
• Pelvic floor or prolapse disorders
• Suspected rectal pathology
• Advanced gynaecological malignancy

6. Completing the examination

1. Remove gloves and allow the patient to dress in privacy.
2. Thank her and ensure she feels well.
3. Explain findings in clear language.
4. Discuss any immediate tests, imaging, treatment or referral.
5. Document:
   • Indication for examination
   • Consent
   • Chaperone name and role
   • Relevant positive and negative findings
   • Samples taken
   • Whether examination was limited, declined or stopped because of pain or distress

Short OSCE sequence