Gynecological assessment, history collection and physical examination

1. “GYNECOLOGOCAL
ASSESSMENT ”
KANCHAN MEHRA
M.SC NURSING 2NDYEAR
PCNMS

2.  A full history and physical examination is equally as
important in evaluating the gynecologic patient as in
evaluating a patient in general medicine or surgery.
 The history-taking and physical examination must be
systematic to avoid omissions, and it should be
conducted with sensitivity and without haste.
 History must be taken in a nonjudgmental, sensitive
and thorough manner Importance must be given
towards maintenance of patient-nurse relationship.
 Always starts by taking consent of the patient.
INTRODUCTION

3. GYNECOLOGICAL
ASSESSMENT
The clinical examination should be thorough and
careful. These include in-depth history taking and
examinations—general, abdominal and internal. The
examination should, in fact, proceed with the
provisional diagnosis in mind.

4. History
collection
For a careful history taking, the following
outlines are of help:
IDENTIFICATION DATA
 Name ..........................
 Age .............................
 Address ......................
 Marital status .............
 Parity .........................
 Social status ...............
 Chief complaint .........

5. Present illness
 The patient is asked to state her main
complaint and to relate her present illness.
 Pertinent negative information should be
recorded, and as much as possible, questions
should be reserved until after the patient has
described the course of her illness.

6. Abnormal
Vaginal
Bleeding
 Vaginal bleeding before the age of 9 years and
after the age of 52 years is cause for concern and
requires investigation.
 Occasionally woman may menstruate regularly
and normally up to the age of 45years

7. Abdominal
Pain
Many gynecologic problems are associated with
abdominal pain.
 The common gynecologic causes of acute lower
abdominal pain are salpingo-oophoritis with
peritoneal inflammation, torsion and infarction
of an ovarian cyst, endometriosis, or rupture of
an ectopic pregnancy.
 Patterns of pain radiation should be recorded.
 It may also be the first symptom of ovarian
cancer.

8. Amenorrhea
The most common causes of amenorrhea are
pregnancy and the normal menopause.
It is abnormal for a young woman to reach the
age of 16 years without menstruating(primary
amenorrhea).
In a patient with amenorrhea who is not
pregnant, inquiry should be made about
menopausal or climacteric symptoms such as
hot flashes, vaginal dryness, or mild
depression.

9. Other
Symptoms
Other pertinent symptoms of concern include-
 Dysmenorrhea
Premenstrual tension
Leukorrhea
Dyspareunia
 Abdominal distention
Lower back and sacral pain may indicate -
uterine prolapse, enterocele, or rectocele.

10. Menstrual
History
 Age of onset of the first period (menarche).
 Regularity of the cycle
 Duration of period
 Length of the cycle
 Amount of bleeding
 First day of the last menstrual period (LMP).
 Inquiry should be made regarding menstrual cramps
(dysmenorrhea); if present, the age at onset, severity,
and character of the cramps should be recorded.

11. Obstetric
History
If the patient had been previously pregnant, details
are to be enquired as per tabulation below. Many a
times, the complaints may be related to the pregnancy
complications or lactation.
year Abortion Preterm/
fullterm/
post term
Mode of
delivery
Presentat
ion/
Position
Gender Live or
Still
birth
Age in
year
2015 -- - - Full term Normal
Vaginal
Delivery
Cephalic male Live 4year

12.  No. of living children...........
 Health status of the baby.............
 Immunization ..............

13. Past /
Present
Medical
History
 Relevant medical disorders—systemic,
metabolic or endocrinal (diabetes, hypertension,
hepatitis) should be enquired.

14. Past /
present
Surgical
History
 This includes general, obstetrical or
gynecological surgery.
 The nature of the operation, anesthetic
procedures.
 Any histopathological report or relevant
investigation.

15. Family
History
 It is of occasional value. Malignancy of the
breast, colon, ovary or endometrium is often
related.
 Tubercular affection of any family member can
give a clue in diagnosis of pelvic tuberculosis.

16. Personal
History
 Occupation,
 Marital status—married, widow, divorcedor
separated should be enquired.
 If married—details of sexual history should be
taken, especially in case of infertility.
 History of taking drugs for a long time or
allergy to certain drugs is to be noted.

17. Contraceptive
history
Sexual history
 The type and duration of each contraceptive method
must be recorded, along with any attendant
complications.
 Inquiry should be made regarding any pain
(dyspareunia), bleeding, associated with sexual
intercourse.

18. GYNECOLOGICAL
PHYSICAL
EXAMINATION
The examination should be systematic and should
include the following points.
 General and systemic examination
 Gynecological examination
- Breast examination
- Abdominal examination
- Pelvic examination.

19. I)General
and
systemic
examination
 The general and systemic examination should be
thorough and meticulous.
 Vital Signs- Temperature, pulse rate, respiratory rate,
and blood pressure should be recorded.
 General Appearance- The patient’s body build,
posture, state of nutrition, demeanor, and state of
well-being should be recorded.period.
 Head and Neck- Evidence of supraclavicular
lymphadenopathy, oral lesions, webbing of the neck,
or goiter may be pertinent to the gynecologic
assessment.

20.  Built—Too obese or too thin—May be the result
of endocrinopathy and related to menstrual
Abnormalities
 Nutrition—Average/Poor
 Stature—including development of secondary
sex characters
 Pallor
 Edema of legs
 Teeth, gums and tonsils

21.  Cardiovascular and respiratory systems—
Any abnormality may modify the surgical
procedure, if it deems necessary
 Heart and Lungs- Examination of the heart and
lungs is of importance, particularly in a patient
who requires surgery. The presence of a pleural
effusion may be indicative of a disseminated
malignancy, particularly ovarian cancer.

22.  Back-Abnormal curvature of the vertebral column
(dorsal kyphosis or scoliosis) is an important
observation in evaluating osteoporosis in a
postmenopausal woman.
 Extremities- The presence or absence of
varicosities, edema, pedal pulsations, and
cutaneous lesions may suggest pathologic
conditions within the pelvis. The height of pitting
edema should be noted.

23. GYNECOLO-
GICAL
EXAMINATION
Breast Examination
 This should be a routine especially in women above
the age of 30 to detect any breast pathology, the
important being carcinoma. In India, breast
carcinoma is the second most common
malignancy in female, next to carcinoma cervix.

24. Examination of the
breasts :
1. Inspection with the arms
sides
2. Inspection with the arms
raised above the head
3. Inspection with hands at
the waist
4. Palpation of the axillary
nodes
5. Palpation of the
supraclavicular nodes
6. Palpation of the outer half
of the breast (a pillow is
placed under the patient
shoulder)

25. Abdominal
examination
Inspection:
The skin condition of the abdomen—
Presence of old scar, striae, prominent veins or
eversion of the umbilicus is to be noted.
In pelvic peritonitis, the lower abdomen is distended
Pelvic tumor is more prominent in the hypogastrium
situated either centrally or to one side.

27. Palpation
 The palpation should be done with the flat of the hand
gently rather than the tips of the fingers.
 If a mass is felt in the lower abdomen, its location, size
above the symphysis pubis, consistency, feel, surface,
mobility from side to side and from above to down,
and margins are to be noted.

28. Types of Palpation:
Light palpation –Depress the skin surface 1 to 2
cm and use a circular motion to feel for easily
palpable organs and masses
Deep palpation –Depression between 2.5 to 5 cm
allowing feeling very deep organs or structures
that are covered by thick muscles
–Most often used for abdominal, male and female
reproductive assessments

29. Percussion
 A pelvic tumor is usually dull on percussion
with resonance on the flanks.
 However, if there are intestinal adhesions or the
tumor is retroperitoneal, it will be resonant.

30. Auscultation
 Ordinarily, auscultation reveals only the
intestinal sounds..
 The uterine souffle may be heard over a
pregnant uterus or
 Vascular fibroid, which is synchronous with the
patient’s pulse.

31. Pelvic
examination
Pelvic examination includes:
 Inspection of the external genitalia
 Vaginal examination
– Inspection of the cervix and vaginal walls
– Palpation of the vagina and vaginal cervix
by digital examination
– Bimanual examination of the pelvic organs
 Rectal examination
 Rectovaginal examination.

32. Position of the Patient
Positions of the patient
for gynecological
examination:
(A). Sims’position left
arm along the back
(B). Dorsal position
C). Lithotomy position

33. Inspection of
the Vulva
 To note any anatomical abnormality starting from
the pubic hair, clitoris, labia and perineum
 To separate the labia using fingers of the left hand
to note external urethral meatus, visible openings of
the Bartholin’s ducts (normally not visible unless
inflamed)
 To ask the patient to strain to elicit:
- Urine comes out through urethral meatus
- Genital prolapse and the structures involved
 Lastly, to look for hemorrhoids, anal fissure, anal
fistula or perineal tear.

34. Inspection of
the vagina and
cervix
 In vagina check any protrusion
 Vaginal discharge-color and odor of discharge
 Any ulceration and bleeding
 And in cervix inspect protruded mass with
bleeding

35.  Cervical scrape cytology and endo-cervical
sampling can be taken as ‘screening’ in the same
sitting
 The cervical lesion may bleed during bimanual
examination, which makes the lesion difficult to
visualize.
 Two types of speculum are commonly used
- Sims’ or Cusco’s bivalve.

36. Palpation by Digital examination
 Digital examination is done using a gloved index
finger lubricated with sterile lubricant.
 Palpation of any labial swelling (commonly
Bartholin’s cyst or abscess) is made with the
finger placed internally and thumb placed
externally.

37. Palpation of
the vaginal
walls
The vaginal area of cervix is palpated to note:
 Direction: In anteverted uterus, the anterior lip is felt
first and in retroverted position , the posterior lip is
felt first
 Station :Normally the external os is at the level of
ischial spines
 Texture: In nonpregnant state, it feels firm like tip of
the nose
 Shape: It is conical with smooth surface in nulliparae
but cylindrical in parous women

38. Bimanual
examination
of pelvic
organ
 The gloved right index and middle fingers
smeared with lubricants are inserted into the
vagina.
 If the introitus is narrow or tender, one finger
may be used. The left hand is placed on the
hypogastrium well above the symphysis pubis
so that the pelvic organs can be palpated
between them.

39. The information obtained by bimanual
examination includes:
 Palpation of the uterus
 Palpation of the uterine appendages
 Pouch of Douglas.

40. Palpation of the uterus
 The two internal fingers, which are placed in the
anterior fornix
 The pressure exerted by the left hand should be
not only downwards but from behind forwards.

41.  The uterine outline between the two hands can thus
be palpated clearly as anteverted. If the uterus is
retroverted,
 After the uterine outline is defined, one should note
its
- position, size, shape, consistency and mobility.

42. Palpation of
the uterine
appendages
 For palpation of the adnexa, the vaginal fingers are
placed in the lateral fornix and are pushed
backwards abdominal hand placed to one side of the
uterus in a backward direction.
 The normal uterine tube cannot be palpated.
 A normal ovary may not be felt. If it is palpable, it
is mobile and sensitive to manual pressure.

43. The pouch of
Douglas
 The pouch of Douglas can be examined
effectively through the posterior fornix.
 Normally, the fecal mass in the rectosigmoid or
body of a retroverted uterus is only felt.
 It should be palpated for masses and tenderness

44. Rectal and Rectoabdominal examination:
Rectal examination can be done in isolation or as an
adjunct to vaginal examination.
Indications
 Painful vaginal examination
 Carcinoma cervix—to note the involvement of the
rectum
 To corroborate the findings felt in the pouch of
Douglas by bimanual vaginal examination
 Atresia (agenesis) of vagina
 Patients having rectal symptoms

45. Recto-vaginal
Examination
 The procedure consists of introducing the index
finger in the vagina and the middle finger in the
rectum.
 This examination may help to determine whether the
lesion is in the bowel or between the rectum and
vagina.
 This is helpful to differentiate a growth arising from
the ovary or rectum

46. SUMMARY
At the end of the Presentation gynecological
assessment can be helpful for students to know
the gynecological assessment that is history
collection and physical examination and
understand the all method of breast examination,
abdominal examination and pelvic examination
that is speculum examination, digital
examination, bimanual examination,
rectoabdominal and rectovaginal examination.

47. ABSTRACT
Patil Suman Shivana gouda, Mahanthshetty Hemalatha, 2019, et al.
was conducted a cross sectional study on Gynecological problems
of adolescent girls attending to rural tertiary care centre at Sri
Devaraj Urs Medical College, Kolar, Karnataka. 720 adolescent
girls (10- 19 years) selected randomly. A pre-tested semi-structured
questionnaire was used to collect information regarding their socio-
demographic characteristics, gynecological history, family history,
obstetric history, documentation of general physical examination.
Result showed that out of the 720, 362 (49.8%) had some type of
menstrual disorders. Out of these 362 cases about 41 of them were a
case of puberty menorrhagia (11.32%) and 89 cases were of
dysmenorrhea (22.37%), 290 (40.2%) of them were diagnosed of
teenage pregnancy. Thus the study concluded there should be
separate adolescent clinics is necessary for efficient management of
menstrual disorders in adolescents.

48. BIBLIOGRAPHY
 Dutta D.C. Textbook of Gynecologgy , 6th Edition.
India. Jaypee Bothers Medical Publisher(P) Ltd: Nov
2013. Pp-99 -108
 Lakshmi seshadri, Essential of Gynecology , 1st Edition.
India. Wolters kluwer Pvt. Ltd: New Delhi 2011. Pp 53-
67
 Hacker and Moore’s, Essentials of Obstetrics and
Gynecology 5th Edition (Saunders Elsevier publisher),
Pp 13-19
 Patil Suman Shivanagouda, Mahanthshetty Hemalatha,
Gynecological problems of adolescent girls attending to
rural tertiary care centre at Sri Devaraj Urs Medical
College, Kolar, Karnataka. International Journal of
Reproduction, Contraception, Obstetrics and Gynecology
[Internet] July 2019 · Volume 8 · Issue 7, Pp 1-4 [cited
on – 28 Feb 2020].Online available at: www.ijrcog.org