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Helen B. Albano, MD, FPOGS

Medical History

The quality of the medical care provided by the


Type of relationship between physician and the

o Can be determined largely the depth of
gynecological history

Patient-Doctor Relationship
o Complete history
o Complete PE
o Labs

New Patient
o Take Time

Obtain comprehensive history

Perform comprehensive PE
o Establish data base, along with DPR basd on
a good communication

Old Patient or the established patient

o Updates

Gynecological changes

Pregnancy history

Additional surgery, accidents or new

History Taking

o Most important part of gynecological
o Provides tentative diagnosis (impression)
before PE
o LEGAL document

Subject to subpoena, may be

defended in court
General Data



Gravidity (G)
o State of being pregnant

Parity (P)
o Outcome of pregnancy
o FPAL (in digits)

F = number of full term pregnancy

P = number of preterm pregnancy

A = Abortion

L = total number of living children

o Ex: G1P0 0001

LMP (Last Menstrual Period)

o Also take the first and last day of normal

PNMP (Previous Normal Menstrual Period)

EDC/EDD and AOG Expected Date of

o Nigellas EDC
3 mos back + 7 + 1year ???
o AOG (wks of gestation)

Date and Time of Consultation/Admission

Chief Complaint

Only one
Reason for admission
Common gynecological complaints
o Bleeding (vaginal)
o Pain (specify: use 9 regions of abdomen)
o Mass (abdominal or pelvic)
o Vaginal discharge
o Urinary or GI symptoms
o Protrusion out of the vagina
o Infertility

HPI (History of Present Illness)

Refers to the chief complaint

o Duration
o Severity
o Precipitating factors
o Occurrence in relation to other events

Menstrual cycle


Bowel movements

History of similar symptoms

Outcome of previous therapies

Impact on the patients:

o Quality of life
o Self-image
o Relationship with the family (sexual history
to husband)
o Daily activities
Menstrual History

Age of menarche

Date of onset of menstrual periods

Duration and quantity (i.e. number of pads used per

day) of flow

Degree of Discomfort

Premenstrual symptoms

o Counted from the first day of menstrual flow
of one cycle to the first day of menstrual
flow of the next

Range of normal is wide

o Normal range of ovulatory cycles

Between 21 & 35 days

o 28-day cycle represent the median cycle
o A recent change in the usual pattern maybe
a more reliable sign of a problem

Average menstrual blood loss

o 30 ml (entire)
o 10-80 ml (normal range)

Excessive menses
o Need to frequently change saturated
sanitary pads or tampons
o Passage of many or large blood clots

o Painful menstruation
o Discomfort or pain at the hypogastric area,
often associated with backache
o Common
o Begins just before or soon after the onset of
o Subsides by day 2 or 3 of flow
o May be associated with systemic symptoms
Obstetric History

Number of pregnancies
Complications of previous pregnancies
o Antepartum, intrapartum or postpartum
Duration of labor
Type of delivery
o Place: hospital, house, hilot, TBA, physician
Anesthesia used
Perinatal status of fetus
o Birthweight
o Early growth and development of children
including feeding habits, growth, overall
well-being, current status
History of Infertility
o Evaluation, diagnosis, treatment, outcome

Medical History


Past and current medical and surgical problems

Previous hospitalizations
o Reason, date, outcome

o Type, date
Surgical History

Operative procedure
o Outcomes
o Complications
o Surgical diagnosis
o Pathologic diagnosis
Review of Systems (subjective)





o Dont combine, as in GU




Breast Symptoms




Family history
Social History

Marital status
o Number of years married
o Period of infertility

Drug (causes abruption placenta), alcohol use,


Occupational History
o Exposure to radiation
o Infectious agents

Sexual History
o Partners, protection from STDs

Emotional or sexual abuse

Family History

Significant medical and surgical disorders that runs

in the family
Heredofamilial diseases

Evaluation of the General Appearance

General Impression
o Level of consciousness
o Ambulatory
o Nutritional state
o Presence of facial or excessive body hair
o Vital signs
Physical Examination (PE)


Follows IPPA (with exception of certain organs)

Head and Neck

Chest and Lungs




Lower extremities

Pelvic examination
Gynecological Examination

Pelvic Examination
o Most commonly performed medical
o Performed during the first visit
o Patient should be encouraged to give
feedback during PE to reduce anxiety
o Lithotomy position

Patient lying on her back with both

knees flexed

Buttocks are positioned at the edge

of the table

The feet are supported by stirrups

o The patient should empty her bladder just
before the examination

Pelvic Examination consist of:

o Inspection

Visual inspection of the vulva

Speculum examination vagina and

o Palpation

Bimanual pelvic examination

o Lithotomy position to allow adequate
o She should be comfortable and properly
o Should not be painful except in:

Virgins and has not used tampons

for menstrual protection

In women with inflammatory


Menopausic nulligravid
Inspection of the Vulva
o The vulva should be examined for:

General state of hygiene

Growth of hair

Regions of ulceration and rash


Labial abnormality

Excessive vaginal discharge

Lochia discharged after

Evidence of perineal trauma from
previous deliveries
Evidence of rectal disease
Bartholins and Skeenes glands can
be inspected and palpated
Presence of ectovaginal fistula or

Guidelines in Daily Pelvic Examination

o The physician should prepare the patient for
any pelvic examination by warning her in
advance and examining fingers and

o Not only because the patient cannot see
what is going on
o But also because the area to be examined is
extremely sensitive, both psychologically
and physically
Inspection of the Vagina and Cervix

Graves Speculum
o Employed for visualization of the vagina and
o Bivalve

Anterior valve shorter than the

posterior valve
Speculum Examination

Techniques that should be remembered in speculum


If for pap smear, the speculum

should be warmed, either by a
warming device or placing in warm
water, if and then it should be

By spreading the labia and placing

some tension on the posterior
fourchet, the speculum can be
gently inserted at an angle of about
45O to avoid the urethra
o Speculum insertion

Placing the tranverse diameter of

the blades in the anteroposterior
position and guding the blades
through the introitus in a downward
motion with the tips pointing toward
the rectum

The anterior wall of the vagina is

backed by the pubic symphysis,
upward pressure causes patient

In the resting state, the vagina lies

on the rectum and actually extends
to the rectum

The speculum should be turned so

that the transverse axis of the
blades is in transverse axis of the

It should now lie inferior to the


With gentle opening of the

speculum, the valves separate and
the cervix can be visualized
The blades should be inserted to
their full length
The cervix is inspected next
It should be pink, shiny and clear
Nulliparous external os should be
Parous external os takes on a
fishmouth appearance

With previous cervical

lacerations, healed stellate
laceration may be found

o The cervix should be inspected for



Degree of discharge (leucorrhea

discharges other than blood)

Evidence of trauma

Presence of lesion
*Pap smear is encouraged if not done yet

Pap Smear

Major objectives:
1. sample exfoliated cells from the
endocervical canal
2. Scrape the transitional zone

A collection of cells from the posterior fornix

(maturation index)
Bimanual Pelvic Exam

After the speculum has been.

It is helpful to place a stool at the base of the

examining table and support the examining arm and
elbow during the examination
o This support of the elbow allows greater
sensitivity in the examining fingers

At the same time, a second dimension is added by

employing the other hand to pressure the abdomen

One hould rquire proficiency with the index and

middle fingers of one hand and then always use that
hand for the vaginal examination as the:
1. Vaginal hand (non-dominant hand)
2. The other as an abdominal hand (dominant
Palpation by Bimanual Examination

Basically allows the physician to palpate the uterus

and the adnexa

The lubricated index and middle fingers of the

dominant hand are placed within the vagina, and
the thumb is folded under
o So as not to cause the patient distress in the
area of the mons pubis, clitoris and pubic

The fingers are inserted deeply into the vagina so

that they rest beneath the cervix in the posterior

The physician should be in a comfortable position,

generally with the leg on the side of the vaginal
examining hand on a table lift and the elbow of that
arm resting on the knee.

The opposite hand is in the patients abdomen

above the pubic symphysis
The first palpable is the cervix
Next is the anteriorly displaced uterus
The flat of the fingers are used for palpation
The uterus is then elevated by pressing up on the
cervix and delivers the uterus to the abdominal
hand so that the uterus may be placed placed
between the two hands
o Identify position, size , shape, consistency
and mobility
The shape of the uterus shuld be described in detail.
The consistency of the uterus is generally firm but
not rock-hard
Any underlying tenderness
o May imply an inflammatory process

Examination of the adnexa

If the right hand is the pelvic hand, the first two

fingers of the right hand are then moved into the
right vaginal fornix as deeply as they can be

Cervical and adnexal tenderness:

o Ectopic pregnancy
o PID/Salphigitis
o Endometriosis

A normal ovary is approximately 3 cm b 2 cm (about

the size of a walnut) and will sweep between the
two fingers with ease unless it is fixed in an
abnormal position by adhesions.

When the adnexa is palpated, its size, mobility and

consistency must be determined

Adnexa are usually not palpable in postmenopausal


If palpable adnexa in menopause may need further

investigation for ovarian pathology, if enlarged
Rectovaginal Examination (read book its beyond my

Confirm bimanual examination


Should be employed in all patients


o Uterosacral ligament

Any thickening or beadiness


If the uterus is retroverted

Summary (inspection and palpation only)

o Leukorrhea

o Color