OBGY - Examination of a Gynaecological Patient (Chapter 9)

INTRODUCTION

• Clinical examination must be thorough and meticulous
• Includes: in-depth history taking + general examination + abdominal + internal examination
• A meticulous history alone can give a positive diagnosis in the majority of cases without physical examination
• Examination should proceed with the provisional diagnosis in mind
• Direct observation of the patient before speaking gives nonverbal clues (fear, sadness, apathy, anger)

PATIENT DETAILS TO RECORD

• Name, Age
• Address
• Marital status, Parity
• Social status
• Chief complaints

HISTORY

1. MENSTRUAL HISTORY

• Age of menarche (onset of first period)
• Regularity of the cycle
• Duration of period
• Length of the cycle
• Amount of bleeding - excess indicated by passage of clots or number of pads used
• First day of LMP (last menstrual period)

Represented as, e.g., 4/28 - onset at age 13, bleeding lasts 4 days, cycle every 28 days

2. OBSTETRIC HISTORY

• Year and events
• Pregnancy events
• Labour and delivery details
• Method of delivery
• Puerperium
• Baby weight and sex, birth asphyxia, duration of breastfeeding, contraception used

• Number of living children (boys/girls)
• Health status of the baby
• Immunisation status
• Date of last childbirth

3. PAST MEDICAL HISTORY

• Systemic, metabolic or endocrine disorders - diabetes, hypertension, hepatitis
• These can complicate operative procedures
• Most important - interrogation about sexually transmitted diseases (STDs)

4. PAST SURGICAL HISTORY

• Nature of previous operation (general, obstetrical, or gynaecological)
• Anaesthetic procedures used
• Bleeding or clotting complications
• Post-operative convalescence
• Any histopathological reports or relevant investigation from previous surgery

5. FAMILY HISTORY

• Malignancy of breast, colon, ovary, or endometrium (often familial)
• Tubercular affection in family members - clue to pelvic tuberculosis

6. PERSONAL HISTORY

• Occupation
• Marital status (married, widow, divorced, separated)
• Sexual history - especially in infertility cases
  • Any sexual dysfunction or dyspareunia
• Contraceptive practice - especially relevant for pill users or IUCD cases
• History of long-term drug use or drug allergy

EXAMINATION

A. GENERAL AND SYSTEMIC EXAMINATION

• Build - obese/thin may suggest endocrinopathy related to menstrual abnormalities
• Nutrition - average/poor
• Facies - acne, hirsutism
• Edema - presence of leg edema
• Neck - goitre (to rule out thyroid dysfunction); palpate thyroid gland and lymph nodes (especially left supraclavicular glands)
• Cardiovascular and respiratory system - any abnormality may modify surgical procedure
• Pulse and blood pressure

B. GYNAECOLOGICAL EXAMINATION

i. Breast Examination

• Routine especially in women above age 35
• To detect breast pathology, particularly carcinoma
• In India, breast carcinoma is the second most common malignancy in females (after carcinoma cervix)

ii. Abdominal Examination

• Bladder must be empty (exception: history of stress incontinence or chronic urinary retention - then catheterise under aseptic precautions)
• Patient lies flat with thighs slightly flexed and abducted (abdominal muscles relaxed)
• Physician stands on the right side
• A chaperone (female) must be present

1. Inspection - skin condition, old scars, striae, prominent veins, umbilical eversion; ask patient to strain to detect incisional hernia or rectus divarication
2. Palpation
3. Percussion
4. Auscultation

• Intestinal obstruction - uniform abdominal distension, thoracic-type respiration
• Pelvic peritonitis - only lower abdomen distended with diminished respiratory movements
• Ascites - fullness in flanks

iii. Pelvic Examination

Source: Chapter 9 - Examination of a Gynaecological Patient, OBGY Textbook

Examination of a Gynaecological Patient

INTRODUCTION

• Examination = thorough history + general + abdominal + internal examination
• Meticulous history alone gives diagnosis in majority of cases
• Observe patient before speaking - nonverbal clues (fear, sadness, anger)

PATIENT DETAILS

• Name, Age, Address
• Marital status, Parity, Social status
• Chief complaints

HISTORY

1. Menstrual History

• Age of menarche
• Regularity of cycle
• Duration & length of cycle
• Amount of bleeding (clots / no. of pads)
• LMP (last menstrual period)
• Represented as e.g. 4/28 = 4 days bleeding, every 28 days

2. Obstetric History

• Year, pregnancy events, labour, mode of delivery
• Puerperium details
• Baby - weight, sex, birth asphyxia, breastfeeding duration
• No. of living children, immunisation, last childbirth date

3. Past Medical History

• Diabetes, hypertension, hepatitis
• History of STDs

4. Past Surgical History

• Type of surgery (general/obstetric/gynaecological)
• Anaesthesia, clotting/bleeding complications
• Previous histopathology reports

5. Family History

• Malignancy - breast, colon, ovary, endometrium
• Tuberculosis - clue to pelvic TB

6. Personal History

• Occupation, marital status
• Sexual history - dysfunction, dyspareunia
• Contraceptive use (pill/IUCD)
• Drug history / allergies

EXAMINATION

A. General & Systemic

• Build - obese/thin (endocrinopathy)
• Nutrition
• Facies - acne, hirsutism
• Edema of legs
• Neck - goitre, lymph nodes (esp. left supraclavicular)
• CVS & respiratory system
• Pulse & BP

B. Breast Examination

• Routine in women >35 years
• Rule out carcinoma
• 2nd most common female malignancy in India (after carcinoma cervix)

C. Abdominal Examination

• Bladder empty (catheterise if chronic retention)
• Patient lies flat, thighs flexed & abducted
• Physician on right side
• Female chaperone present

1. Inspection - scars, striae, veins, umbilicus; strain to detect hernia/rectus divarication
2. Palpation
3. Percussion
4. Auscultation

• Intestinal obstruction → uniform distension, thoracic respiration
• Pelvic peritonitis → lower abdomen distended, reduced movements
• Ascites → flank fullness

D. Pelvic Examination

• Breast examination
• Abdominal examination
• Pelvic examination