GYNECOLOGY  Only one Helen B. Albano, MD, FPOGS  Reason for admission  Common gynecological complaints Medical History o Bleeding (vaginal)  The quality of the medical care provided by the o Pain (specify: use 9 regions of abdomen) physician o Mass (abdominal or pelvic)  Type of relationship between physician and the o Vaginal discharge patient o Urinary or GI symptoms Can be determined largely the depth of o o Protrusion out of the vagina gynecological history o Infertility  Patient-Doctor Relationship o Complete history HPI (History of Present Illness) o Complete PE  Refers to the chief complaint o Labs o Duration  New Patient o Severity o Take Time o Precipitating factors . Obtain comprehensive history o Occurrence in relation to other events . Perform comprehensive PE . Menstrual cycle o Establish data base, along with DPR basd on . Voiding a good communication . Bowel movements  Old Patient or the established patient  History of similar symptoms Updates o  Outcome of previous therapies . Gynecological changes  Impact on the patient’s: . Pregnancy history o Quality of life . Additional surgery, accidents or new o Self-image medications o Relationship with the family (sexual history to husband) History Taking o Daily activities  Overview o Most important part of gynecological Menstrual History evaluation  Age of menarche o Provides tentative diagnosis (impression)  Date of onset of menstrual periods before PE Duration and quantity (i.e. number of pads used per o LEGAL document  . Subject to subpoena, may be day) of flow defended in court  Degree of Discomfort  Premenstrual symptoms General Data  Cycle  Name o Counted from the first day of menstrual flow  Age of one cycle to the first day of menstrual  Gravidity (G) flow of the next o State of being pregnant  Range of normal is wide Normal range of ovulatory cycles  Parity (P) o . Between 21 & 35 days o Outcome of pregnancy 28-day cycle represent the median cycle o FPAL (in digits) o . F = number of full term pregnancy o A recent change in the usual pattern maybe . P = number of preterm pregnancy a more reliable sign of a problem . A = Abortion  Average menstrual blood loss . L = total number of living children o 30 ml (entire) o 10-80 ml (normal range) o Ex: G1P0 0001  Excessive menses  LMP (Last Menstrual Period) o Need to frequently change saturated o Also take the first and last day of normal sanitary pads or tampons menstruation o Passage of many or large blood clots  PNMP (Previous Normal Menstrual Period)  Dysmenorrhea  EDC/EDD and AOG – Expected Date of o Painful menstruation Confinement/Delivery o Discomfort or pain at the hypogastric area, o Nigella’s EDC often associated with backache 3 mos back + 7 + 1year ??? . o Common o AOG (wks of gestation) o Begins just before or soon after the onset of bleeding o Subsides by day 2 or 3 of flow  Date and Time of Consultation/Admission o May be associated with systemic symptoms Chief Complaint Obstetric History  Number of pregnancies  Significant medical and surgical disorders that runs  FPAL in the family  Complications of previous pregnancies  Heredofamilial diseases o Antepartum, intrapartum or postpartum  Duration of labor Evaluation of the General Appearance  Type of delivery  General Impression o Place: hospital, house, hilot, TBA, physician o Level of consciousness  Anesthesia used o Ambulatory Nutritional state  Perinatal status of fetus o Presence of facial or excessive body hair o Birthweight o Vital signs o Early growth and development of children o including feeding habits, growth, overall Physical Examination (PE) well-being, current status  (objective)  History of Infertility  Follows IPPA (with exception of certain organs) o Evaluation, diagnosis, treatment, outcome  Head and Neck  Chest and Lungs Medical History  Heart  Allergies  Breast  Past and current medical and surgical problems  Abdomen  Previous hospitalizations  Lower extremities o Reason, date, outcome  Pelvic examination  Vaccination o Type, date Gynecological Examination  Pelvic Examination Surgical History o Most commonly performed medical  Operative procedure procedure o Outcomes o Performed during the first visit o Complications o Patient should be encouraged to give o Surgical diagnosis feedback during PE to reduce anxiety o Pathologic diagnosis o Lithotomy position . Patient lying on her back with both Review of Systems (subjective) knees flexed  Pulmonary . Buttocks are positioned at the edge  Cardiovascular of the table  Gastrointestinal . The feet are supported by stirrups  Genital o The patient should empty her bladder just before the examination  Urinary o Don’t combine, as in GU  Pelvic Examination consist of: o Inspection  Vascular . Visual inspection of the vulva  Neurologic . Speculum examination – vagina and  Endocrinologic cervix  Immunologic o Palpation . Bimanual pelvic examination Breast Symptoms o Lithotomy position to allow adequate  Masses exposure  Galactorrhea o She should be comfortable and properly  Pain draped  Family history o Should not be painful except in: . Virgins and has not used tampons Social History for menstrual protection  Marital status . In women with inflammatory o Number of years married processes o Period of infertility . Menopausic nulligravid  Drug (causes abruption placenta), alcohol use, smoking Inspection of the Vulva  Occupational History o The vulva should be examined for: o Exposure to radiation . General state of hygiene o Infectious agents . Growth of hair  Sexual History . Regions of ulceration and rash o Partners, protection from STDs . Discoloration  Emotional or sexual abuse . Labial abnormality . Excessive vaginal discharge Family History  Lochia – discharged after . With gentle opening of the delivery speculum, the valves separate and . Evidence of perineal trauma from the cervix can be visualized previous deliveries . The blades should be inserted to . Evidence of rectal disease – their full length hemorrhoids . The cervix is inspected next . Bartholin’s and Skeene’s glands can . It should be pink, shiny and clear be inspected and palpated . Nulliparous – external os should be . Presence of ectovaginal fistula or round prolapsed . Parous – external os takes on a fishmouth appearance Guidelines in Daily Pelvic Examination  With previous cervical  Warning lacerations, healed stellate o The physician should prepare the patient for laceration may be found any pelvic examination by warning her in  Inspection advance and examining fingers and o The cervix should be inspected for speculum . Color  Important: . Erosion o Not only because the patient cannot see . Degree of discharge (leucorrhea – what is going on discharges other than blood) o But also because the area to be examined is . Evidence of trauma extremely sensitive, both psychologically . Presence of lesion and physically *Pap smear is encouraged if not done yet

Inspection of the Vagina and Cervix Pap Smear  Grave’s Speculum  Major objectives: o Employed for visualization of the vagina and 1. sample exfoliated cells from the cervix endocervical canal o Bivalve 2. Scrape the transitional zone . Anterior valve shorter than the  A collection of cells from the posterior fornix posterior valve (maturation index) Speculum Examination  Techniques that should be remembered in speculum exam Bimanual Pelvic Exam . If for pap smear, the speculum  After the speculum has been…. should be warmed, either by a  It is helpful to place a stool at the base of the warming device or placing in warm examining table and support the examining arm and water, if and then it should be elbow during the examination lubricated o This support of the elbow allows greater . By spreading the labia and placing sensitivity in the examining fingers some tension on the posterior  At the same time, a second dimension is added by fourchet, the speculum can be employing the other hand to pressure the abdomen gently inserted at an angle of about  One hould rquire proficiency with the index and 45O to avoid the urethra middle fingers of one hand and then always use that Speculum insertion o hand for the vaginal examination as the: . Placing the tranverse diameter of 1. Vaginal hand (non-dominant hand) the blades in the anteroposterior 2. The other as an abdominal hand (dominant position and guding the blades hand) through the introitus in a downward motion with the tips pointing toward Palpation by Bimanual Examination the rectum  Basically allows the physician to palpate the uterus . The anterior wall of the vagina is and the adnexa backed by the pubic symphysis,  The lubricated index and middle fingers of the upward pressure causes patient dominant hand are placed within the vagina, and discomfort. the thumb is folded under . In the resting state, the vagina lies o So as not to cause the patient distress in the on the rectum and actually extends area of the mons pubis, clitoris and pubic to the rectum symphysis . The speculum should be turned so  The fingers are inserted deeply into the vagina so that the transverse axis of the that they rest beneath the cervix in the posterior blades is in transverse axis of the fornix vagina . It should now lie inferior to the  The physician should be in a comfortable position, cervix 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 patient’s abdomen o Color above the pubic symphysis  Cervix  The first palpable… is the cervix o  Next is the anteriorly displaced uterus o  The flat of the fingers are used for palpation o  The uterus is then elevated by pressing up on the  Uterus cervix and delivers the uterus to the abdominal o hand so that the uterus may be placed placed o between the two hands o o Identify position, size , shape, consistency  Adnexa and mobility o  The shape of the uterus shuld be described in detail. o  The consistency of the uterus is generally firm but o 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 inserted  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 women  If palpable adnexa in menopause may need further investigation for ovarian pathology, if enlarged

Rectovaginal Examination (read book… its beyond my powers…)  Confirm bimanual examination   Hemorrh    Should be employed in all patients  After…    o Uterosacral ligament .  Any thickening or beadiness (endometriosis/inflammation)  If the uterus is retroverted

Summary (inspection and palpation only)  o  o   Vagina o Leukorrhea