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Full gynecological history and pelvic examination

Full gynecologic history and the pelvic examination is a part of the assessment of female patients in many clinical conditions. Noting the history is the initial step in the physician–patient meeting. This provides a basis for the subsequent physical examination, and for further decisions about diagnostic testing and treatment.

The information obtained during this physical examination helps the doctor to cut down the list of possible diagnoses. The process of taking Gynecological history involves a series of methodical questioning by the Gynaecologist. The further procedure involves examination of the patient, further investigative testing or treatment of a diagnosed condition. There is a basic structure for taking gynecological histories but this can differ slightly depending on the presenting complaint.

General gynecologic history

Basic Information

  • Name of patient
  • Age of patient
  • Marital Status

Chief Complaint

It is important to know the present problem

History of Presenting Complaint

  • If pain is involved -site, type and intensity
  • Onset
  • Periodicity
  • Duration
  • Recurrence?
  • Aggravating & relieving factors
  • Severity

Menstrual History

  • Menarche and menopause
  • last menstrual period
  • Length of bleeding (days)
  • Frequency
  • Regularity
  • Associated pain (dysmenorrhea, mittelschmerz)
  • Bleeding between periods
  • Bleeding after intercourse
  • Any post menopausal bleeding
  • Nature of periods
  • Heavy?
  • Clots?
  • Flooding?

Past Gynecological History

  • Gynecological symptoms
  • Gynecological diagnoses
  • Gynecological surgery
  • Date & result of cervical smears
  • Contraception

Past Obstetric History

  • Gravidity and Parity
  • Dates of deliveries
  • Length of pregnancies
  • Normal Delivery?
  • Weight of babies
  • Sex of babies
  • Complications before, during and after delivery

Past Medical History

  • Current or past illnesses
  • Hospital admissions
  • Past surgeries
  • Infection
  • History of sexually transmitted infections
  • History of vaginitis, including types, frequency, and treatment
  • History of pelvic inflammatory disease

Fertility/infertility History

  • Planning for future fertility
  • Any difficulty conceiving in past? If so, prior evaluation and treatments

Drug History

  • Prescribed medications
  • Non-prescribed medications/herbal remedies
  • Recreational drugs
  • Any known drug allergies

Contraceptive History

  • Any recent unprotected intercourse.
  • Potential contra-indications to different methods.
  • Permanent or temporary method required

Personal History

  • Sleep
  • Appetite
  • Micturation
  • Defecation
  • Weight loss or gain
  • Addiction

Family History

  • Medical conditions
  • Gynecological conditions
  • Malignancies
  • Consanguinity

Social History

  • Occupation
  • Support network
  • Smoking
  • Alcohol
  • Marital status

Pelvic Examination

The gynaecologic examination includes examination of the breasts, abdomen, and pelvic region. The doctors usually do this to get a visual and physical examination of a woman’s genital system. It includes examination of organs including the vulva, vagina, uterus, ovaries, and Fallopian tubes, the bladder and rectum. Palpation is also performed, to feel the size and shape of the pelvic organs.

What is the need of Pelvic Examination?

A pelvic exam is usually performed to check for symptoms such as abnormal bleeding, unusual vaginal discharge, or pain as part of a regular checkup. Pelvic examinations are also carried out during pregnancy check-ups. It is also necessary for cervical cancer screenings, in which few sample of cells from the cervix are taken for microscopic examination like Pap smear.

Patient Positioning

The pelvic examination is usually performed in a lying-on-back position on the examination table with the flexing of the knees and the feet are kept in supporting stirrups. The patient’s head is often raised with a pillow by elevating the head of the examining table. In this position, the patient can have better eye contact with the doctor, which usually helps the patient relax.

Equipment

To perform a pelvic examination the doctor should have a good light source, sterile gloves, a speculum of, and water-soluble lubricant. A variety of the most commonly used specula, materials with which to obtain cervical cytologic samples, fixative, and large cotton-tipped swabs should be ready in the examination room. Swabs and culture media for the collection of samples, saline wet mounts, as well as pH paper should be on hand.

How is a pelvic exam performed?

Pelvic examination does not require the patient to do any special preparation. The speculum, usually a metal or plastic instrument, is inserted into the vagina to allow full visual of the vaginal walls and cervix. A brush or a small spatula takes a small sample of the cells of the cervix for the Pap test. Though there is some discomfort, a pelvic exam is not painful.

A bimanual exam is another method of pelvic examination. This involves placement of two fingers inside the vaginal canal and pressing lightly on the lower abdomen with the other hand to palpate the pelvic organs. A rectal exam is also carried out at the time. It can reveal any enlarged organs or tissue masses.

  

 

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