[GYNECOLOGY] HISTORY, PHYSICAL EXAMINATION, AND PREVENTIVE HEALTH CARE – DR.

GABALDON

INTRODUCTION TO GYNECOLOGY: HISTORY, PHYSICAL  Be non-judgmental

EXAM, AND PREVENTIVE HEALTH CARE
Dr. Gabaldon
OBJECTIVES
 Reproductive Anatomy (reading assignment)
 Display the components of effective physician
communication Accomplish a thorough and complete
history, including sexual history Perform a complete physical
and gynecologic exam
 Formulate an annual health care plan for Filipino women
GYNECOLOGY
Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier
 The study of diseases of the female reproductive organs,
including the breasts
 Encompasses surgical and nonsurgical expertise
 Does not mean to say that all patients need to
undergo surgery since this is a surgical field  You will
have to identify and determine who among your
patients need to undergo surgery and who among
them only needs conservative treatment
 It is frequently studied and practiced in conjunction with
obstetrics
 “The physician practicing obstetrics and gynecology should
not assume that the patient's general medical needs are
cared for by others but should assume the role of her primary
physician.”
 Most of the time our female patients will not know
any other physicians aside from their obstetrician.
 Also, most of the time, the first time that they go see
a doctor is because they are pregnant  They will
expect you to just refer them to other specialists if the
need will arise
 That means it is important for us to take a complete
history and physical examination so that we would
be able to identify the presence of comorbidities or
any conditions that would mean referral to other
specialists
COMPONENTS OF EFFECTIVE PHYSICIAN COMMUNICATION
 Be culturally sensitive
 Bear in mind that you will not only handle Filipino
patients. Even if you are practicing in the Philippines,
you will have patients coming from different
nationalities and different religion.
 Your approach to the patient will all depend on the
patient’s religion or cultural practices.
 Establish rapport
 Patients will know if you really care 
 Listen and respond to the woman’s concerns (empathy)
 It is not our role to judge whether what the patient did
was right or wrong.
 Our role is to counsel our patients and not to
reprimand them.
 Include both verbal and non-verbal communication
 Engage the woman in discussion and treatment options
(partnership)
 Your patient is your partner in treatment
 You are not supposed to dictate to your patient the
treatment option that should be done to her  You
give her all the pertinent information about her
disease, all the management options, explain to her
the prognosis and the complications that she may
encounter and then allow her to decide for herself
 Convey comfort in discussing sensitive topics
 Abandon stereotypes
 True among HIV-positive patients  One of the
reasons why they are hesitant to seek consult is
because even health professionals isolate them
 Check for understanding of your explanations
 Ask the patient to repeat whatever it is that you told
them
 Remember that not all patients have the same level of
understanding
 Support  Help the woman to overcome barriers to care and
compliance with treatment
ESSENCE OF THE GYNECOLOGIC HISTORY: PERTINENT
GYNECOLOGIC HISTORY
HISTORY OUTLINE
 Observation – nonverbal clues
 Chief Complaint
 History of Gynecologic Problems
 Significant Health Problems
 Medications, Habits, Allergies
 Bleeding Problems
 Family History
 Occupational and Vocational History
 Social History
 Review of Systems
 Head
 Cardiovascular
 Respiratory
 Gastrointestinal
 Genitourinary
 Neuromuscular
 Psychiatric (depression/anxiety)
 Physical abuse (incest/rape)

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 [GYNECOLOGY] HISTORY, PHYSICAL EXAMINATION, AND PREVENTIVE HEALTH CARE – DR. GABALDON

NON-VERBAL CLUES  Represents a chronologic history of the current problem

 Look at her even before speaking!
 5 General Impressions MENSTRUAL HISTORY
 Happiness  Age of menarche
 Self-assured, good personal control, relaxed face with a  Duration of each monthly cycle
smile  Duration of menses
 Apathy  Regularity of the menstrual cycles
 Blank facial expression; eyes lack sparkle; mouth is in  LMP and PMP
neutral position
 LMP  Last NORMAL menstrual period
 Slouched posture, weak handshake
 Short and unemotional responses  Characteristics of menstrual flow
 Fear  Accompanying symptoms
 Tense facial expression; tight mouth; darting and
narrow eyes VAGINAL BLEEDING
 Perspiring but with dry mouth; endless hand activity  Ovulatory Cycles
 Reacts out of proportion to offered stimuli  Menstruation that occurs monthly (range 21 to 40 days),
 Anger lasts 4 to 7 days, bright red, and often accompanied by
 Narrowed eyes, furrowed brows, narrow and tight lips cramping on the day preceding and the 1st day of the
 Radiated aggression harsh voice period
 Overreaction to questions involves short threatening  Anovulatory Cycles
phrases  Menstruation that is irregular, often dark in color,
 Sadness painless, and frequently short or very long
 Slouched shoulders; large sad eyes; turned down mouth  Common among teenagers and premenopausal women
 Eyes may glisten with tears; turned down mouth  Intermenstrual Bleeding
 Speech reflects remorse and hopeless ness  Vaginal bleeding not related to menses
 Post-coital Bleeding
 4 Important Qualities in Caring Communication Skills  Postmenopausal Bleeding, including menopausal
 Comfort symptoms and HRT use
 Acceptance
 Responsiveness HISTORY OF PREVIOUS PREGNANCIES
 Empathy  Year of pregnancy
 Duration
CHIEF COMPLAINT  Type of delivery
 Reason for seeking help  Size, sex, and current condition of the baby
 Concise statement describing the woman’s problem in her  Pregnancy and delivery complications
words  Breastfeeding history
 Pregnancy termination and spontaneous abortions
 In obstetrics, if the patient came for an elective cesarean
section, instead of writing “Chief Complaint”, you write  Ectopic and molar pregnancies including type of therapy
“Reason for Admission”  Father of each pregnancy
 Number of sexual partners and risk for STD

HISTORY OF PRESENT ILLNESS HISTORY OF VAGINAL AND PELVIC INFECTION

 Among our pregnant patients, we do not place there  Types of infection and treatment
“History of Present Illness,” instead we write “History of  Complications
Present Pregnancy” since pregnancy is not an illness.  Risk factors for HIV
 HIV screening offered if appropriate
 Patient presents the problem as she sees it in her own words
 Should only be interrupted for clarifications or to offer  Routinely offered  Up to the patient if she
direction decline/refuses or not
 Physician should acknowledge important points  Need for hospitalization and outcome
 Open-ended questions should be asked to clarify specific
points PAP SMEAR SCREENING HISTORY
 Patients will not volunteer information  It is up to us  Date of last pap smear
to obtain the information that we need  Screening frequency

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 [GYNECOLOGY] HISTORY, PHYSICAL EXAMINATION, AND PREVENTIVE HEALTH CARE – DR. GABALDON

 Abnormal test results and treatment  Binge drinking

 HPV vaccination status  Previous therapy for alcoholism
 Contraceptive History
 Method used FAMILY HISTORY
 Duration  First-order relatives
 Effectiveness  Serious illness
 Complication  Cause of death
 Congenital malformation
GYNECOLOGIC SURGICAL PROCEDURES  Mental retardation
 Dates  Pregnancy loss
 Type of procedure
 Diagnoses OCCUPATIONAL AND SOCIAL HISTORY
 Significant complications  Spouse’s occupational history
 Hobbies and vocations
IMPORTANT POINTS OF SEXUAL HISTORY  Where and with whom the woman lives
 When you ask about the sexual history, it is important  Other individuals in the household
that you make the patient understand that this is going  History of travel
to be confidential between you and the patient alone.  Unusual experience
 It is also very important that when you do sexual history
taking, no one is around, not even the husband. SAFETY ISSUES
 Ask DIRECTLY and CLEARLY  Use of seat belts and helmets
 Identify sexual behaviors  Firearms in the household
 Intimate partner violence
 Sexual activity
 Sensory impairment
 Types of relationships  Physical activities
 Individual(s) involved
 Satisfaction? Orgasmic? Desire/Interest? REVIEW OF SYSTEMS
 Dyspareunia  Medical Conditions
 Sexual Dysfunction (Patient/Partner)  Serious headaches, epileptic seizures, dizziness, fainting
 General Organ System
6 COMMON QUESTIONS THAT SHOULD BE ASKED ABOUT  Constitutional systems
PAIN  EENT
1. Location  Skin problems
2. Timing  Diet habits
3. Quality  Musculoskeletal problems
4. Intensity  Cardiovascular/Respiratory History
5. Duration  Hypertension, heart disease, rheumatic fever
6. What causes the pain to worsen or subside including  Chest problems
association with menstruation
 GI Disorders
 Gas or stool incontinence
GENERAL HEALTH HISTORY
 Genitourinary System
 Significant health problems during her lifetime  Bladder dysfunction, dysuria, Incontinence, Infections,
 Medications taken, reasons, and allergic responses Urinary frequency, nocturia
 Bleeding and clotting problems  Neurologic or Neuromuscular Impairment
 Smoking History  Endocrine Symptoms
 Amount  Diabetes mellitus and thyroid disease
 Length of time
 History of Vascular Disease
 Attempts at quitting
 Thrombophlebitis with or without pulmonary embolism,
 Use of illicit drugs varicose veins, or other vascular problems
 Length of use
 Psychiatric History
 Type of drugs used  Emotional or mental disease processes
 Side effects  Depression and suicidal ideology
 Alcohol  Physical and sexual abuse
 Number of drinks per day

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 [GYNECOLOGY] HISTORY, PHYSICAL EXAMINATION, AND PREVENTIVE HEALTH CARE – DR. GABALDON

ESSENCE OF COMPLETE PHYSICAL EXAMINATION  Nipple discharge

 Complete PE should be performed at the 1st visit and at each  Breast fixation
annual checkup  Tissue thickening
 The patient should disrobe completely and cover herself  Palpable masses
with a hospital gown that ensures warmth and modesty  Evaluation for axillary and supraclavicular lymphadenopathy
 Drape your patients properly
ABDOMINAL EXAMINATION
 The patient should be allowed to maintain personal control  Inspection
 If she tells you that she doesn’t want a speculum exam  Symmetry
and internal exam even if you tell her that you need to  Scars, protuberance or discoloration of the skin
do that  In spite of your counseling and explanation  Suggest previous surgeries
the patient still doesn’t want, don’t let it be, wag ipilit!
 Striations suggesting previous pregnancies and adrenal
 Ask her to sign a refusal form
gland hyperactivity
 Presence of a chaperone may offer warmth, compassion,  Hair Pattern
and support to the patient during uncomfortable or  Female Escutcheon  Inverted triangle over the mons
potentially embarrassing portions of the examination pubis
 Male Escutcheon  Hair growth between the area of
GENERAL EVALUATION the mons pubis and the umbilicus (diamond pattern)
 Appearance and affect
 Weight, height, BMI and blood pressure

EENT
 Annual fundoscopic examination
 Inspect for evidence of upper lip or chin hair, which may
indicate increased androgen activity

NECK  Palpation
 Palpate thyroid gland  Organomegaly
 Adenopathy along the supraclavicular and posterior  Liver, spleen, kidneys, and uterus, adnexal masses
auricular chains  Fluid wave
 Ascites/Hemoperitoneum
CHEST  Abdominal rigidity
 Symmetry of movement  Spasm of the rectus muscles secondary to
 Percussion for areas of consolidation intraabdominal irritation
 Auscultation for breath and adventitious sounds  Rebound tenderness
 May signify an acute abdomen
HEART
 Point of maximum impulse  This would tell us that this patient would need
exploratory laparotomy  Surgical approach
 Percussion for size
already
 Auscultate for irregularities of rate and evidence of murmurs
 Auscultate in both lying and sitting positions  Groin
 Adenopathy
CLINICAL BREAST EXAMINATION ELEMENTS  Inguinal hernias
 Examination of each breast with the patient sitting with
arms raised, and with the patient supine  Percussion
 Attention to the entire breast mound from mid-sternum to  Used to differentiate fluid waves
the posterior axillary line and from the costal margin to the  To outline solid organs and masses
clavicle
 Inspection and Palpation to assess:  Auscultation
 Skin flattening or dimpling  Hypoactive may indicate ileus
 Skin erythema
 Important especially to patients who are Status
 Skin edema Post-Exploratory Laparotomy
 Nipple retraction
 Nipple eczema

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 [GYNECOLOGY] HISTORY, PHYSICAL EXAMINATION, AND PREVENTIVE HEALTH CARE – DR. GABALDON

 Hyperactive may indicate intrinsic irritation or partial or  Any pus expressed from the urethra should be
complete bowel obstruction submitted for Gram stain and cultured (frequently
gonococci)
PELVIC EXAMINATION  Bartholins Glands
 The patient is lying supine with legs in stirrups
 Found at the 5 and 7 o’clock position of the vulva
 Lithotomy Position  Clinical Significance:
 Obstruction of the ducts would cause
 The physician should be sure that the patient is as relaxed as
possible enlargement of the vulva
 Secondarily infected  Bartholin’s Gland Abscess
 Describe the procedure first and allow the shy or nervous
patient to prepare herself  Palpate the posterior 3rd of the labia majora, placing
 Allow the patient to adjust, relax, and open up her legs the index finger inside the introitus and the thumb on
by herself the outside of the labium
 Note for enlargements or cysts
 Vagina
 Ask the patient to bear down, note for any bulging:
cystocoele, cystourethrocoele, rectocoele, organ
prolapse
 Prolapse Disorders  Secondary to weakening of
pelvic floor muscles

 Inspection
 Mons Pubis
 Quality and pattern of hair
 Areas of alopecia
 As a woman ages, the pubic hair becomes less dense
and may turn gray
 Evidence of body lice
 Skin of the Perineum
 Redness, excoriations, discolorations, loss of pigment
 Presence of vesicles, ulcerations, pustules, warty
 Accurate evaluation of pelvic organ prolapse is improved
growths, neoplastic growths, pigmented nevi
by examining the woman standing with her legs spread
 Varicose veins
apart and with a Valsalva maneuver
 Skin Scars
 Indicating previous episiotomies
 Clitoris
 Size and shape, usually 1.-1.5 cm in length
 Labia Majora and Minora
 Any irregularities and evidence of trauma
 Introitus
 Is the hymen intact, imperforate, or open? Is it gaping
or not?

 Palpation
 Use the second and fourth fingers of the gloved hand
separating the labia minora
 Urethra
 Length of the urethra is palpated and milked with the
middle finger  Note for inflammation or pus

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 [GYNECOLOGY] HISTORY, PHYSICAL EXAMINATION, AND PREVENTIVE HEALTH CARE – DR. GABALDON
SPECULUM EXAMINATION
Graves Speculum
 Small  For young children, women with tight perineal
repairs and aged patient with severe involution
 Medium  Most women
 Large  Obese, grand multiparas
Pederson Speculum
 Narrower than graves speculum
 For women who have not become active sexually, have
never been pregnant, or have not used tampons
 Make sure that you choose the appropriate size of
speculum depending on the patient
 Speculum should be warmed and then touched to the
patient's leg to determine that she feels the temperature is
appropriate and comfortable
 Speculum is then inserted by placing the transverse
diameter of the blades in the anteroposterior position and
guiding the blades through the introitus in a downward
motion with the tips pointing toward the rectum
 Blades should be inserted to their full length and then
opened so that the physician may inspect for the position of
the cervix
 Vagina
 Inspect for erythema or lesions
 Fluid discharge should be evaluated for pH, by wet smear
and KOH smear
 Cervix
 Should be pink, shiny and clear
 Nulliparous  Round external os
 Parous  Fish-mouth appearance
 Cervical lacerations  Healed stellate lacerations
 Inspect the transformation zone (the junction of
squamous and columnar epithelium)
 Junction between the columnar epithelium of the
endocervix and the stratified squamous epithelium
of the ectocervix  Squamo-columnar Junction
 Before the age of puberty: Squamo-columnar
cannot be seen
 At the time of puberty, when the patient engage
in coitus, at the time of menses, and pregnancy:
Cervix everts  Expose the squamo-columnar
junction
 Metaplasia  Exchange one normal type of
epithelium with another type of normal epithelium
 Squamous Metaplasia  Columnar epithelium will
be replaced by a squamous epithelium
 Transformation Zone  Site of HPV infections, site
of CIN, Cervical CA
 Nabothian cysts resulting from a process of metaplasia
 At the time of squamous metaplasia, wherein a
columnar epithelium is being replaced by squamous
epithelium  Cover the opening of the glands 
Continuous secretion = Form Nabothian Cysts
 Ectropion
 Area of eversion of the external os so that the
reddened columnar epithelium is visible on the
anterior and posterior lips of the cervix
 Not an evidence of pathologic condition
 Lesions should be noted and biopsy performed when
appropriate
PAPANICOLAOU SMEAR
 Screening tool for cervical neoplasm
 Initial Screening: Should begin at age 21 regardless of when
sexual activity began
 Younger individuals can easily clear the HPV  If you
are able to clear the virus, it won’t develop
 Persistence of HPV would depend on the age  Older
age, immunocompromised individuals, individuals
with chronic debilitating diseases = At risk for
persistence of HPV infection
 Interval
 Every 1 – 2 years (ages 21 – 29)
 Every 3 years for low-risk individuals after age 30 if 3
consecutive pap smears are negative
 Annually for high-risk individuals
 High-Risk Individuals Necessitating Annual Screening
 HIV positive
 Immunosuppressed
 DES exposure
 History of dysplasia or cervical cancer
 Criteria for Discontinuation of Screening
 Age 65 – 70
 Provided that they are not high-risk individuals
 Have 3 consecutive negative screens in the prior decade
 After total hysterectomy for benign conditions
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 [GYNECOLOGY] HISTORY, PHYSICAL EXAMINATION, AND PREVENTIVE HEALTH CARE – DR. GABALDON

 Continue Screening if: Lubricated index and middle fingers of the dominant hand
 With new sex partner are placed within the vagina, and the thumb is folded under
 Supracervical hysterectomy so as not to cause the patient distress.
 With history of prior dysplasia

 Major Objective
Fingers are inserted deeply into the vagina so that they rest
 Sample exfoliated cells from the endocervical canal
beneath the cervix in the posterior fornix.
 To scrape the transitional zone

The opposite hand is placed on the patient's abdomen

above the pubic symphysis. The flat of the fingers are used
for palpation.

Physician then elevates the uterus by pressing up on the

cervix and delivering the uterus to the abdominal hand so
that the uterus may be placed between the two hands.

 The endocervical canal is sampled with either a cotton- Identify uterine position, size, shape, consistency, and
tipped applicator or a cytobrush, which is placed into the mobility.
canal and rotated. The cytobrush give more accurate results
and higher yields of positive findings.
 The material obtained is smeared thinly on a microscope
slide by rotation of the swab or brush on the glass surface Enlargement of the uterus should be described in detail,
size may be compared to weeks of gestation.
 Labeled endocervix and fixed immediately either by use of a
spray fixative or by immersion of the slide into a fixative
solution
 5 Months Size  At the level of the umbilicus
 4 Months Size  Between the symphysis pubis and the
umbilicus
 3 Months Size  At the level of the symphysis pubis

 Used even if the woman is not pregnant

 Normal Uterus
 May be anteflexed, retroverted, or midposition
 Pear shaped
 Generally mobile
 Surface is smooth
 The entire transformation zone is scraped using the Ayres  Consistency – firm but not rock hard
spatula and the sample smeared thinly on a second slide,  Any undue tenderness upon palpation may imply
which is immediately fixed inflammatory process
 Sample of the vaginal pool, may be taken with the reverse
side of the Ayres spatula and smeared on a third slide or on
a second portion of the slide containing the transformation
zone material

BIMANUAL EXAMINATION
 Internal Examination  Insert fingers in the vagina
 Allows the physician to palpate the uterus and the adnexa

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 [GYNECOLOGY] HISTORY, PHYSICAL EXAMINATION, AND PREVENTIVE HEALTH CARE – DR. GABALDON

 Examination of the Adnexae RECTOVAGINAL EXAMINATION

 The first two fingers are moved to the right vaginal fornix
The middle finger is lubricated and inserted into the
as deeply as they can be inserted rectum, index finger is reinserted into the vagina.
 Abdominal hand is placed just medial to the ASIS on the
right, two hands are brought as close together as possible

The rectovaginal septum is palpated between the 2 fingers,

any thickness or mass is noted.

Palpate for the uterosacral ligaments for any thickening or

beadiness may imply inflammatory reaction or
endometriosis

The rectum is palpated in all dimensions by the examining

finger.

Note the tone of the anal sphincter, abnormalities such as

 If the right hand is the pelvic hand, the first two fingers hemorrhoids, fissures, masses.
of the right hand are then moved into the right vaginal
fornix as deeply as they can be inserted.
THE ANNUAL HEALTH CARE PLAN
 The abdominal hand is placed just medial to the LONG-TERM GOALS OF ANNUAL VISITS AND PREVENTIVE
anterior superior iliac spine on the right, the two CARE
hands are brought as close together as possible, and  To maintain the woman in the best health and functional
with a sliding motion from the area of the anterior status possible
superior iliac spine to the introitus, the fingers are  To promote high quality longevity
swept downward, allowing for the adnexa to be  To aid in early detection of disease
palpated between them.
GOOD HEALTH HABITS
 A normal ovary is approximately 3 cm by 2 cm (about  Eat moderately
the size of a walnut) and will sweep between the two  Eat a healthy diet focusing on fruits, vegetables, whole
fingers with ease unless it is fixed in an abnormal grains, and foods low on saturated fats
position by adhesions.  Eat breakfast
 Be tobacco free
 When the adnexa is palpated, its size, mobility, and  Exercise regularly
consistency should be described.  Use alcohol in moderation
 Sleep 7-8 hours per night Stay at a healthy weight
 Adnexa are usually not palpable in postmenopausal
women. SUGGESTED LABORATORY STUDIES FOR ANNUAL HEALTH
MAINTENANCE VISIT
 A palpable organ in such an individual may need  13-18
further investigation for ovarian pathology, if  HPV Vaccine, (one series between age 9 and 26)
enlarged.  Hepa B Vaccine (if not immunized)
 Tdap Booster (once between 11 and 18 years)
 Normal Ovary
 3 x 2 cm and will sweep between the 2 fingers with ease  19-39
unless it is fixed  Pap Test (Start at age 21)
 Size, mobility, and consistency  Tdap once and Td (every 10 years)
 Any palpable organ may need further investigation for  HPV Vaccine (one series between age 9-26)
ovarian pathology if enlarged.  Fasting Lipid Profile (every 5 years starting age 20)
 HIV (once between 19 and 64)

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 [GYNECOLOGY] HISTORY, PHYSICAL EXAMINATION, AND PREVENTIVE HEALTH CARE – DR. GABALDON

 40-64
 Pap Test
 Mammography
 Fasting Lipid Profile (every 5 years)
 Colorectal screening (>50 y/o)
 Tdap once and then Td (every 10 years)
 TSH (every 5 years beg at age 50)

 65 and older
 Pap Test
 Mammography
 Fasting Lipid Profile
 Colorectal Screening
 Bone Density Screening (every 2 years)
 TSH
 Influenza vaccine yearly

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