1、Gynecological history and pelvic examination Dr. Fanjiangtao The First Affiliated Hospital of GXMU,History-taking is the basic procedure to make diagnosis. We should not only have the fundamental knowledge of gynecology but also have the communication skills (a good listener). The history record is
2、not simply making a list of what the patient has told us and what we found in examination. We must review our data, organize them, evaluate the importance and relevance of each item, and construct a clear, concise, yet comprehensive record.,The basic requirement in writing a gynecological history re
3、cord,To be objective and accurate and concise To write down in the time order To use the professional terms Not to erase more than 3 places in the history record-otherwise rewrite them Signature/date Consent with the patient,Outline of gynecological history,General information,name ,gender, age, occ
4、upations, address, race, nationality, the marital status, admission date, the time of record, the reliability of the history teller,Chief complaint,Its the main symptom and duration of onset. We can estimate the preliminary scope of the disease based on the chief complaint. We can start with whats k
5、ind of problem are you having? or what can I help you? Usually the chief complaint is no more than 20 words. It should be stated as nearly as possible in the patients tone and words.,The example of chief complaint,Vaginal bleeding for 3 days after 60 days cessation of menstruation. Pelvic mass was f
6、ound by ultrsound exam for 3 months.,Present illness,We must obtain each of the problem the patient described in detail. We can question what exactly the problem is, where exactly it is occurring, the date and the time of onset, whether the symptoms are abating or getting worse . The effect of treat
7、ment before and the influence on daily life .,Present illness,To use the words or terms that can be easily understood by the patient when you question or talk to them, because the patient may be lack of the knowledge of medicine.,Menstrual history,age at menarche interval between periods duration of
8、 flow amount and character of flow degree of discomfort (dysmenorrhea?) age at menopause last menstrual period (LMP) previous menstrual period (PMP) is expressed as a fraction-13 5/28 2016-02-13,Gravidity and parity(1),Age at marriage The health status of husband Obstetric history: date of birth, ty
9、pe of delivery, sex and weight of offspring, postpartum hemorrhage or infection The pattern of recording:2-1-1-3 2 termed pregnancy, 1 premature delivery, 1 abortion, and 3 living children G4P3,Gravidity and parity(2),The type of contraception and the effect The date of last delivery/abortion The im
10、pact of these processes in relation to ectopic pregnancy, infertility, et al must be elicited.,Past history,It includes the patients general condition before suffering the present illness. Particularly importance is the illness in the major organ system (heart, kidney, lung, and liver). Any medicati
11、ons are being taken should be described. The history of operation, allergies to drugs or foods, and the vaccination should be recorded.,Personal history,The type of job , the degree of education, her community activities, and the living environment , et al. Smoking, alcohol ingested (the amount and
12、the duration) Sexual history, including gonorrhea, syphilis, exposure to HIV, hepatitis, chlamydia, and papillomavirus.,Family history,This section is mainly related to genetic disease of the patients family, as well as the relatives. Such as the heart disease, vascular disease, diabetes, and hemato
13、logic abnormalities. Some kind of malignant tumor are genetic, such as breast cancer and ovary cancer.,Physical examination,General examination Abdominal examination Pelvic examination,General examination,Vital signs: temperature, pulse, respiration, and blood pressure. Weight and height Nutrition,
14、body development, et al.,Abdominal examination,Inspection: the contour and colour of the abdominal wall Auscultation: the gurgling sound of intestine Palpation: to detect the rigidity, voluntary guarding, masses, and tenderness. Percussion: to help to identify the organ enlargement, tumor, or ascite
15、s.,Pelvic examination(1),The patient would feel embarrassed and anxiety when she has the pelvic examination for the first time. So the attitude of the physician is very important to get her cooperation. Explanation and verbal consent; quiet room and private area for the patient to undress; Female ch
16、aperone; Ultrasound examination and anesthesia can be helpful sometime. passing a speculum, taking cervical smear, and performing a bimanual pelvic examination,Pelvic examination(2),The patient should empty her bladder; Undress herself below the waist; Lie on the supine position; The disposable glov
17、es, speculum and lubricating gel immediately to hand; Good illumination;,External genitalia,The pattern of pubic hair distribution; The skin of vulva, mons pubis and perineal area (infection); External condylomata or other tumors; Vestibular glands (finger inside and thumb outside to feel the cyst);
18、 The form of hymen (unmarried, married without birth, multiparous ) Urethrocele, cystocele, rectocele or uterine prolapse ( to ask the patient to bear down or in upright position),Vaginal examination,Inspected for abnormalities with the speculum and obtain the Pap smear; The cervix and fornices shou
19、ld be thoroughly exposed ; the contour of cervix, the external os, the depth of fornices, the character of discharge and the color of vaginal wall; Palpation of the vagina in bimanual examination.,Bimanual examination,Using two fingers in the vagina and the flat of opposite hand placed on the lower
20、abdominal wall to feel the position, size, shape, mobility, consistency, and the tenderness of pelvic structures. Sometimes only one finger used for the patients introitus is too small-postmenauposal women,Bimanual examination,Cervix: to know the consistency and the mobility of the cervix(mobile pai
21、n?). Corpus of the uterus: anteverted/retroverted; size, shape, position, consistency and mobility. Adnexa: include fallopian tube and ovaries; We should pay more attention to any enlargement and tenderness of the adnexal structures(for further diagnostic procedures).,Bimanual examination,Rectovagin
22、al examination,Gently insert your middle finger into the rectum and then the index finger into the vagina to feel any tenderness, masses, or irregularities. This kind of examination can easily find some aspects of the posterior portion of the pelvis, especially in the situation of tumor or endometri
23、osis.,Record of the pelvic exam,External genitalia: condition of development, marriage and parity(with several birth of children, the hymen will disappear almost) Vagina: any obstruction and abnormal discharge Cervix: size, contour, consistency,tumor? Corpus of uterus: position, size, shape, tendern
24、ess, mobility Adnexa: any mass and tenderness,Diagnosis lab test,Test for vaginal infection Pap smear Biopsy Colposcopy Hysteroscopy Culdocentesis Ultrsonography,Test for vaginal infection,A culture is obtained by applying a cotton-tipped applicator to the suspected discharge and sent to lab- the go
25、lden standard method. Direct microscopic examination of the discharge is a routine examination in the clinic-more convenient but with lower accuracy.,Pap smear(1),Its an important screening method for early cervical cancer,esp for the age more than 30 years. Just lubricate the speculum with water. A
26、fter exposing the cervix, the physician rotate the wooden scraper or a brush for several round to abrade the surface slightly and to obtain the epithelial cells from the squamocolumnar area of cervical os.,The ThinPrep Technique(TCT) used in clinics can provide accurate data to physician,Pap smear(2
27、),Remember that Pap smear is just a screening method for cervical cancer or precancer, not the confirmative diagnosis, so if there is any positive finding, further diagnostic procedure such as biospy, colposcopy should be performed.,Biospy,Its the gold standard to confirm or verify the suspected dia
28、gnosis. Its common applied in the cervix, vulva, endometrum for oncology diagnosis. Its also helpful in diagnosis of ovarian dysfunction. We usually take 4 biospies at 12,3,6, and 9 oclock of the cervix. (iodine test-Schiller test derected, often in the squamocolumnar junction),colposcopy,Its routin
29、ely used for management of abnormal pap smears and is able to see areas with cellular dysplasia, vascular or tissue abnormalities and then to help select the area for biospy. The 3-step procedure for management of cervical lesion: Pap smear-colposcopy-biopsy,hysteroscopy,Its the visual examination o
30、f the uterine cavity. Its used to evaluate the abnormal uterine bleeding, removal of polyps and IUDs, resection of submucous myoma, and endometrial ablation. Complications: perforation, infection, bleeding,culdocentesis,The passage of a needle into the cul-de-sac in order to obtain fluid from the po
31、uch of Douglas is a diagnostic method . It can be performed under the direction of B-type ultrasound or in the office. We can diagnose the disease just by the character of fluid obtained from culdocentesis.,ultrasonography,B-type ultrasound examination is a simple, painless, repeatable and free of r
32、adiation hazard procedure. Indications: early pregnancy, ectopic pregnancy, pelvic mass, the size of follicle, obese patient , or the patient without cooperation. Abdominal scan, vaginal probe scan,Common symptoms of gynecology,Abnormal vaginal bleeding Abnormal leucorrhea Pelvic mass Pelvic pain,Ab
33、normal vaginal bleeding(1),Bleeding can come from any part of the female genital tract, including uterus, cervix, vagina, hymen. In most cases, it comes from uterus. In some cases, vaginal bleeding is a part of systemic disease, such as blood disease, which can be ignored by the gynecologist.,Causes
34、 of abnormal vaginal bleeding,Dysfunctional uterine bleeding or other endocrinopathies Infections(cervicitis, vaginitis, endometritis and cervical polyps,et) Oncology-related (benign or malignant) Pregnancy-related bleeding(EP, spontanoues abortion, et) Trauma or foreign body in the reproductive tra
35、ct, IUD insertion As a part symptoms of other systematic disease, such as blood system or liver disease.,Patterns of abnormal vaginal bleeding,Patterns of abnormal vaginal bleeding,Menometrorrhagia: is bleeding that occurs at irregular intervals. Oligomenorrhea: menstrual interval is longer than 35d
36、ays. Amenorrhea: absence of menses for more than 6months. Contact bleeding: cervical cancer? Cervical erosion? cervical polyps? Cervical infection? Postmenopausal bleeding: bleeding occurs after 12months of amenorrhea.,Diagnosis of abnormal vaginal bleeding(5),History taking Initial lab tests: pregn
37、ancy test, complete blood cell count, uterine examination, LH/FSH, liver/kidney function tests, pelvic ultrasound examination, et al.,Abnormal leucorrhea(1),Its usually a whitish vaginal discharge. Its origin site includes cervix, vagina (exudation/secretion), vulva, upper genital tract. Common caus
38、es: infection of cervix or vagina, uterine tumor, foreign body, estrogen depletion.,Types of abnormal leucorrhea(2),Mucous discharge: yellow in color-STD? Foamy discharge: trichomoniasis vaginitis Cheesy discharge: thick, cheese-like, accompanied with a burning sensation or intensive pruritus, assoc
39、iated with vulvovaginal candidiasis. Fishy discharge: thin, white, malodorous, bacterial vaginosis.,Abnormal leucorrhea(3),Purulent discharge: greenish, micropurulent discharge, gonorrheae, tumor, foreign body, et al. Bloody discharge: genital cancer, cervical polyps, sever cervical erosion, myomas,
40、 IUDs. Watery discharge: may caused by cervical or vaginal carcinoma, or even tumor of fallopian tube.,Pelvic mass(1),Enlargement of uterus: pregnancy, myoma of uterus, carcinoma of uterus. Adnexal mass: (1)some masses due to egg formation, ovulation, corpus luteum formation that less than 5-6cm are
41、 physiologic. (2)an adnexal mass with or without abdominal pain accompanied with vaginal bleeding or cessation of menstruation in a child-bearing aged woman should consider EP.,Pelvic mass(2),Adnexal mass: (3)cystic masses of the ovary are over 5-6cm in the reproductive age woman and over 2cm in pos
42、tmenopausal woman or premenarche girl are always operated to rule out the maligmancy. (4)complex adnexal masses: inflammatory disease, tuberculosis, endometriosis, metastatic nongynecologic cancer.,Pelvic mass(3),Intestinal mass: appendiceal abscess, post-operation adhesion at adnexa. Urinary tract
43、mass: (1)bladder distension may be mistaken as huge cyst mass.(2) pelvic kidney Mass in peritoneal cavity or on the abdominal wall: huge ovarian cyst may be confused with large ascites.,Pelvic mass(4),Physical examination: abdominal and pelvic examination (bimanual and rectovaginal exam) Benign tumo
44、rs are usually cystic, mobile, unilateral, and do not cause ascites. Malignant tumors are usually solid, fixed, and nodular and may cause ascites. Ultrasonography can be helpful.,Pelvic pain,This is the complicated topic. Pelvic pain may be associated with infectious peritoneal distention or tumor.
45、Some of them cannot find causes. Pelvic pain can be categorized into acute pelvic pain, cyclic pelvic pain and chronic pelvic pain.,Acute pelvic pain(1),Pelvic pain with pregnancy: ectopic pregnancy, threatened abortion, inevitable abortion, molar pregnancy. Ovarian cyst and mass: rupture, torsion,
46、hemorrhage of the tumor. Acute pelvic infection: is usually bilateral and associated with lower abdominal pain and cervical motion tenderness, accompanied with fever, leukocytosis and purulent cervical discharge. A therapeutic trial of antibiotics may be helpful in differentiating the infectious and
47、 oncologic disease.,Acute pelvic pain(2),Uterine myoma: red degeneration of myoma , torsion and necrosis of subserous myoma can cause severe pain . Gastrointestinal inflammation: right lower abdominal pain -appendicitis,Cyclic pelvic pain,Premenstrual syndrome (PMS): 7-10 days before the menses Midc
48、ycle pain due to ovulation: rupture of the follicle and the irritation of the peritoneum. The pain can resolves spontaneously. Dysmenorrhea: primary or secondary Endometriosis: can be cyclic in early stage, then occur at variable times.,Chronic pelvic pain(1),Its a major challenge because of its unc
49、lear etiology, complex natural history, and poor response to therapy. It can involve several organs or systems. Gynecologic, gastrointestinal, urinary tract problem, muscloskeletal disorder, psychosocial factors,Chronic pelvic pain(2),Gynecologic causes: Adhesions resulting from previous surgery or pelvic infection. Chronic pelvic inflammatory disease: laparoscopy and peritoneal fluid culture. Pelvic congestion syndrome: its thought to be caused by congestion of the pelvic veins. Dyspareunia: endometriosis, pelvic adhesion, pelvic relaxation, uterus prolapse, and uterine
