dr.

Sigit Nurfianto, SpOG(K)

Depart. Of Obstetrics & Gynecologic Faculty of Medicine

Palangkaraya University
 I. GYNECOLOGICAL HISTORY

A complete picture of the patient and her

illness
A strongly presumptive diagnosis can frequently
be made from the history alone
The patients full name, her husbands, age,
social condition (single, married, divorced, or
separated), address, referring physician, and
health or hospital insurance, husbands job.
1. Patients complaint
The general nature of the patients complaint
In the patients own language.

2. Family history
Familial diabetes, tuberculosis, or cancer.
Cancer is not directly hereditary.
3. History
Previous illnesses especially of any operations
4. Menstrual history
Menstrual symptoms are of more significance
than any other in gynecological patients.
Menarche ?, menopause ?
Should include any forms of contraception
a. Age at Onset
An unusually early menarche, maybe indicative
of certain endocrinopathies

b. Interval
Usual menstrual interval is 28 days,

c. Duration
A prolonged flow being usually an excessive
one, and a very short period being scanty,
but a two-to seven day flow represents
normal variation.
d. Amount
Variations in the amount of blood lost at
menstruation
A marked diminution is suggestive of an
endocrine or constitutional abnormality
Menstrual excess is produced by either
functional or structural lesions, often the
latter.

e. Character of menstrual discharge.

Dark venous appearance, and normally is
unclotted.
Menstruation is excessive, however, the
blood may be right red with clots.
f. Menstrual pain.
Pain with menstruation is one of the most common
of gynecological symptoms,
Anatomical or structural character, for often
constitutional, psychogenic, and other general
factors may be concerned.
g. Intermenstrual bleeding.
After coitus or other contact ?
Most characteristic symptom of early cervical
cancer.

h. The date of the last menstrual period.

Find the patients memory very hazy,
Great importance, as in cases of possible early
gestation, intra or extra uterine.
5. Vaginal discharge
Leukorrhea is such a common gynecological
symptoms
The duration of the leukorrhea, the character,
color, possible odor, and possible irritativeness
of the discharge are among the items of inquiry.

6. Obstetrical History
The history of the pregnancies and labors, with
especial reference to their number, character,
and possible complications.
Miscarriages or abortions, either spontaneous or
induced.
7. Urinary Symptoms
Increased frequency, pain, incontinence,
nocturia, and hematuria.

8. Gastrointestinal Symptoms
Anorexia, bloating, belching, and discomfort
after eating, may be secondary to gynecological
disease, or they may suggest functional or
organic abnormalities of the abdominal viscera.
The possibility of pregnancy,
Constipation is especially common in
gynecological patients
9. Present Illness

History of the present illness, which

constitutes a summation of those previously
mentioned.
Chronological appearance of all gynecological
symptoms
Evaluation of the sexual habits are of
particularly importance in the infertility
problems.
 II. GYNECOLOGIAL EXAMINATION

Naturally be directed chiefly toward the pelvic and

abdominal organs, it must include a general survey of the
entire physical make-up.

1. General
Among the general items : are the height, weight,
and general build of the patient
The thyroid, the heart and lungs
The blood pressure, pulse, respiration, temperature
2. Examination of the Breast
Hyperpigmentation, milk production.

3.Abdominal Examination ( After voiding )

Simple inspection :
Abnormalities of asymmetrical contour, pubic
hair distribution. Any masses or tenderness
Certain cardinal areas, especially the adnexal
regions, McBurneys point, the gall bladder
region, the epigastric and the kidney areas.
Previous surgical scars
Palpation
An abnormal mass of any kind is felt, its position and
its relation to any abdominal or pelvic organ its size,
shape, contour, consistency, movability, and
tenderness or lack of tenderness.

Percussion
Ovarian cysts, which must be distinguished from
ascites and bowl adhesion. Sonar is often helpful
4. Pelvic Examination
Preparation and Position of the Patient
The clothing having been removed, the patient lies in
the dorsal recumbent position, with flexed thighs
and knees, the feet resting on the stirrups of the
examination table, and the limbs and lower abdomen
being draped with a sheet
The presence of a nurse, or of a female relative of
friend
The patients bladder be emptied just before the
examination.
The examining hand is covered with a rubber or
throw-away plastic glove
Inspection
Careful inspection of the external genitalia
The presence of any anatomical or pathological
abnormalities
The presence of any skin lesions or of any
inflammation or irritation of the vulvovaginal mucosa
and urethra
The presence or absence of the hymen, the size of
the clitoris, etc.
Speculum

Speculum examination of the cervix is performed before

pelvic examination,
Smear should be performed at least annually; in addition
visualization of the cervix may provide certain
information.
The presence of polyps, erosion, eversion, or retention
cysts
The vaginal mucosa.
 The Gonococcus may be sought for and cultured from the
secretion from the cervical canal or urethra, whereas the
Trichomonas can be found in the exudate obtained from
the speculum in the posterior fornix.
Speculum inspection of the cervix is in cases of suspected
malignancy of the cervix
One or more fingers well lubricated, are then
introduced into the vagina

Degree of any cystocele, rectocele, or uterine

descensus which may be present.
Unmarried patients with intact hymen,
digital examination of the internal genital
impossible or very painful,
by rectal examination
Examination under anesthesia is desirable,
especially in the case of young girls, obese or
clinical staging of cervical cancer
The examination of the internal genitalia

Begins with careful palpation of the cervix, making

note of such data as its size and shape,
Digital contact with the cervix causes bleeding, as
it so commonly does with certain lesions (polyp,
cancer).
The examining fingers now seeks to determine the
size, shape, and position of the uterus, and the
external hand is called into play, and the real
bimanual procedure begins.
5. Examination of the Rectum

Examination of the rectum is of importance,

especially in those cases in which rectal
symptoms, especially bleeding or pain, have been
complained of.
Combined examination, with one finger in the
vagina and one in the rectum ( recto vaginal
examination ) will be informative to detect recto
vaginal lesion, parametria and posterior side of
uterus evaluation.
III. GYNECOLOGICAL DIAGNOSTIC PROCEDURES

1. Dilatations and Curettage

Most common operation performed by the
gynecologist, to investigate any atypical or
irregular bleeding

2. Biopsy
Supplement smear with a colposcopically directed
biopsy whenever the smear is other than negative
or if there is a suspect pattern by colposcopy
To obtain adequate bits of tissue
3. Schiller Test

Application of iodine solution (Gram or Lugol)

may show normal epithelium in deep mahogany
color, whereas cancer areas are unstained and
present in sharp distinction.
Unfortunately, trauma and various benign
inflammation processes may like wise lead to a
positive Schiller test
Visualy inspection with
Acetoacetic acid aplication
( VAI = IVA )

Inspect the uterine cervix,

after applying 3 - 5% Acetoacetic acid
ectocervix will become coagolate and shrink
nucleous more prominent opaque
white epithelium
4. Conization of the cervix
Conization of the cervix for diagnostic purpose
should be the next step after a doubtful or a
positive smear.
Could detect ecto and endocervix and the deep of
microinvasion
A hot conization which is done with the
electrocautery
A cold conization is simply done with a sharp knife.
5. Colposcopy
The colposcopy is an instrument by which the
cervix may be visualized in bright under 10 to
40 x magnification.
Detect contour, epithel and vascular pattern

6. Colpomicroscopy
The colpomicroscope gives a higher magnification
than the colposcope
Biopsy, Conization, Dilatation and Curretage

Cytopathology, and histopathology are

complementary, not competitive.
As the early endocervical lesions (dysplasias and
in situ) are exremely friable and easily rub off
on every gentle manipulation, endocervical
biopsies or conization should be obtained before
any instrumentation or dilatation of the canal.
7. Endoscopy procedure that uses narrow telescope
to view the interior of a viscus space

a. Laparoscopy.
Direct visualization of the peritoneal cavity

b. Hysteroscopy.
Direct visualization the inside of the uterus,
IV. GYNECOLOGIC CLINICAL CYTOPATHOLOGY

Clinical Application
Papanicolaou and Traut initially introduced this
technique into clinical medicine in 1943.

Technique for proper cellular specimen

So many methods have been devised and advocated
for preparation of specimens for cellular
examination that it may first seem unnecessarily
complicated to the clinician.
 V. LABORATORY EVALUATION

1. A blood count including hematocrit, white cell

count, and platelet count
2. Serum chemistries and liver function testing
3. Coagulation studies.
4. Immunologic test
5. Urine analysis
6. Vaginal secret analysis
 VI. RADIOGRAPHIC, ECG, and
IMAGING STUDIES

However, women over 40 years of age and those

undergoing major gynecologic surgical procedures
should have a chest x ray, electrocardiography, and
serum electrolyte analysis preoperatively.
Radiographic evaluation of adjacent organ systems
should undertaken in individual cases.
1. Intravenous pyelography is helpful to delineate
ureteral patency and course, especially in the
presence of a pelvic mass, gynecologic cancer, or
congenital mullerian anomaly.
2. A barium enema or upper gastrointestinal series
with small bowel assessment may be of
significant value is evaluating some patients
before undergoing pelvic surgery
3. Other imaging studies, including ultrasound, CT
scanning, or magnetic resonance imaging (MRI),
are useful only in selected patients n