HISTORY TAKING AND EXAMINATION IN GYNECOLOGY E.pptx

History taking obg menstrual hostory

1. HISTORY TAKING AND EXAMINATION IN GYNAECOLOGY BY: Dr Smita , Dr Ravali 1 ST YR OBG PGS

2. Patient Particulars Name : for Identification Age : Infants and fetus – structural abnormalities and trisomy AUB is more common in menarcheal and perimenopausal age group AUB in reproductive age 35- 45yr Ca Cervix 55-70yr Endometrial Cancer NO age limit for Ovarian cancer, but most common in elderly or in younger age Address: Occupation: Married/Unmarried: Husband’s Occupation: Religion: Parous/Nulliparous:

3. COMPONENTS OF HISTORY TAKING Patient Particulars Chief Complaints History of Presenting illness Menstrual History Obstetrics History Contraceptive history Sexual history Family history Past medical history Personal history Drugs and Allergy history

4. SOCIOECONOMIC STATUS MODIFIED KUPPUSWAMY CLASSIFICATION

5. SOCIOECONOMIC CLASS

6. CHIEF COMPLAINTS Lower abdominal pain Bleeding Per Vaginum / Abnormal uterine Bleeding Amenorrhea Discharge per Vaginum Mass per Abdomen / Vagina Urinary Problems

7. HISTORY OF PRESENTING ILLNESS

8. LOWER ABDOMINAL PAIN Site of pain Its nature Severity Onset of pain Duration or timing Radiation Relieving factors Exacerbating factors Any associated symptoms – bowel or bladder Association with menstruation

9. ACUTE cause : Acute PID, torsion of ovarian tumor, ectopic pregnancy, incomplete abortion, dysmenorrhea. CHRONIC cause : endometriosis, Adenomyosis , Leiomyoma, chronic PID, pelvic Adhesions, any bowel or urologic cause must be considered. Dysmenorrhea : cyclical pain during menstrual cycle incapacitating to the women from normal activity. PRIMARY : most intense just before or during period. dysrhythmic uterine contractions and uterine hypoxia. PGF-2alpha – uterine myometrial ischemia SECONDARY : increased tension in pelvic tissues d/t premenstrual pelvic congestion or increased vascularity in pelvic organs. endometriosis, adenomyosis , PID, outlet obstruction, IUCD in utero, endometrial polyp, submucous fibroid.

10. ABNORMAL UTERINE BLEEDING Duration of flow Regularity Amount of bleed Passage of clots Number of pads changed per day Previous menstrual cycle flow Last coital history ? For postcoital bleed

11. CAUSES: PALM-COEIN P: Polyp A: Adenomyosis L: Leiomyoma M: Malignancy and hyperplasia C: Coagulopathy O: Ovulatory dysfunction E: Endometrial disorders I:- Iatrogenic N: Not otherwise classified

12. AMENORRHOEA Primary Amenorrhea : Absence of menses by age 16 years Absence of breast development or menses by age 14 years Secondary Amenorrhea : If established menses have ceased for longer than 6 months without any physiological reasons. CAUSES: PHYSIOLOGICAL CAUSES : Before puberty, during pregnancy, during lactation, following menopause. Primary : CAUSES : delayed puberty, turner syndrome, rokitansky kuster hauser syndrome, Androgen insensitivity syndrome, congenital adrenal hyperplasia, imperforate hymen. SECONDARY : CAUSES: premature ovarian failure, PCOS, Sheehan’s syndome , malnutrition, hypothyroid state, diabetes, stress.

13. DISCHARGE PER VAGINUM Amount Color Odour Presence of blood Presence of itching ? Relationship to menstrual cycle Any H/O STD or recent tests Any vaginal dryness

14. Physiological : B efore ovulation: excessive cervical mucus discharge, clear, transparent, copious and stretches like egg white. After ovulation: discharge becomes thick and less in amount. Infective: Candidiasis, Trichomoniasis , Bacterial Vaginosis Itching + WDPV = Candidiasis or Trichomoniasis Candidiasis: creamy white, thick curdy, associated with marked vulvar itching, soreness Trichomoniasis : fishy, frothy, clean, yellowish green, associated with vulvar soreness, itching Bacterial Vaginosis: clear, whitish grey, fishy odour Ca Cervix: Discharge is mixed with blood

15. MASS PER ABDOMEN / VAGINA Site of mass, Progression Abdominal bloating Lower abdominal pain Bowel or Urinary complaints

16. Causes of mass per vaginum : Pelvic organ prolapse – uterine prolapse, cystocele, rectocele, enterocele Gartner’s duct cyst Cervical polyp Chronic inversion of uterus Elongation of cervix Cervical growth Causes of lump lower abdomen: Full bladder Pregnancy Ovarian tumor Uterine fibroid Large tubo -ovarian mass Peritonitis

17. UTERINE PROLAPSE

18. URINARY PROBLEMS Burning micturition, frequency of micturition, painful micturition Urgency , nocturia , bed wetting Hematuria CAUSES: UTI, Vesicovaginal fistula, ureterovaginal fistula, stress incontinence, urge incontinence.

19. MENSTRAUL HISTORY Age of Menarche Last Menstrual Period Cycle length and regularity Days of flow Amount of bleeding: Number of pads changed per day Passage of clots Associated symptoms : Lower pain abdomen (severity, time of onset, any medication taken), Backache Any inter-menstrual or post coital bleeding ? MENOPAUSE : Date of last period, any post-menopausal symptoms, any menopausal symptoms AMENORRHEA : Primary or Secondary ?

20. Menorrhagia or Heavy Menstrual Bleeding : excessive menstrual bleeding (>80ml/cycle) in duration/amount where cycle length is normal. Hypomenorrhea : reduced blood flow either in amount or in duration or in both with cycle length normal. Polymenorrhea or Epimenorrhea : short cycle (<24days) associated with menorrhagia, known as POLYMENORRHAGIA. Cycle length >38 days, known as OLIGOMENORRHEA. Metrorrhagia : IMB(intermenstrual bleeding): bleeding between periods suggesting hormonal, endometrial or cervical pathology. Postmenopausal bleeding: bleeding P/V after 1yr of permanent cessation of menstruation. Menopause: after 1yr of cessation of menstruation, it is declared.

21. When is menstrual bleeding considered “heavy ”? Any of the following is considered to be heavy menstrual bleeding: Bleeding that lasts more than 7 days. Bleeding that soaks through one or more tampons or pads every hour for several hours in a row. Needing to wear more than one pad at a time to control menstrual flow. Needing to change pads or tampons during the night. Menstrual flow with blood clots that are as big as a quarter or larger.

22. CAUSE OF HMB : Fibroids  and  polyps Adenomyosis Irregular  ovulation : areas of the  endometrium  (the lining of the  uterus ) can become too thick. This condition is common during   puberty  and  perimenopause . ALSO SEEN IN  polycystic ovary syndrome  and  hypothyroidism . Bleeding disorders – VWD, hemophilia, platelet disorders. Medications—Blood thinners and aspirin can cause heavy menstrual bleeding. The copper  intrauterine device (IUD)  can cause heavier menstrual bleeding, especially during the first year of use. Cancer—Heavy menstrual bleeding can be an early sign of  endometrial cancer . Most cases of endometrial cancer are diagnosed in women in their mid 60s who are past  menopause . It often is diagnosed at an early stage when treatment is the most effective. Other causes— Endometriosis  can cause heavy menstrual bleeding. Other causes include those related to pregnancy, such as  ectopic pregnancy  and  miscarriage .  Pelvic inflammatory disease  also can cause heavy menstrual bleeding. Sometimes, the cause is not known.

23. Assessment of Quantity of Blood loss : Measurement of Hb from sanitary pad Hb and hematocrit estimation Number of pad or tampoon and amount of passing clot Clinically: < or = 3hr pad change Change of pad at night > 21 pads per cycl e Passage of clots > 1inch >80ml blood loss in each menstrual period Clinical anemia

24. OBSTETRIC HISTORY Married life ? Consanguinity ? Parity ? Last child birth ? Mode of delivery ? Where? Birth spacing ? Obstetric Score Birth weight of baby Indication for LSCS Any complications ? Before, during, after delivery Induction methods used ? Sterilization details ?

25. CONTRACEPTIVE HISTORY Any contraception used ? (husband / wife) (IUCD may cause menorrhagia, OC pills break through bleeding, LNG-IUS is a/w amenorrhea) Type Duration Any complication faced ? Past history of sterilization?

26. SEXUAL HISTORY Age at coitarche Date of most recent sexual activity Number of recent partners Gender of partner Use of condom as barrier protection Method of birth control Prior STD history h/o dyspareunia ?

27. CAUSES of dyspareunia : Pelvic endometriosis, prolapsed uterus and pelvic infection Introital infection or trauma. Vaginal dryness is most common in menopause VAGINISMUS : pain on penetration due to involuntary contraction of pelvic floor mostly of psychological origin.

28. PAST HISTORY Medical : HTN, DM, TB, Hepatitis, HIV, thyroid disorder (E Ca : DM, HTN, Obesity) H/o coagulation disorder H/o blood transfusion STD, Endocrinological disorders Previous H/O of PID Surgical: C-Sec, Appendix, Ovarian cyst, Myomectomy Previous GYN history

29. FAMILY HISTORY Any genetic disorder: Androgen insensitivity syndrome, turner syndrome, premature menopause. H/O of ovarian/ breast/ endometrial cancers ? H/o birth of baby with congenital abnormalities or chromosomal disorder.

30. PERSONAL HISTORY Diet Appetite: sudden loss of weight and anorexia in ovarian malignancy In young, loss of weight + anorexia = anorexia nervosa Sleep Bowel: constipation is common in enterocoele and cervical fibroid TENESMUS in deep endometriosis diarrhea in pelvic abscess, Bladder: H/o stress incontinence, frequency and retention of urine. Habits : smoking/ alcohol

31. DRUG HISTORY H/o of any drug allergy ? H/o intake of corticosteroids, antiepileptic or anticoagulant. thyroxine or any other hormone like estrogen. Estrogen and aspirin therapy should be stopped before surgery.

32. GYNECOLOGICAL EXAMINATION CONTENTS General & Systemic Examination Gynecology Examination Breast Examination Abdominal examination Pelvic Examination

33. INTRODUCTION Gynecological examination confirms presence of pathology suspected from the gynecological history. Always explain to the patient about the need and the nature of the proposed examination. Obtain an informed verbal consent. The examiner (male or female) should be accompanied by another female (chaperone). Examination performed in a private setting, respecting patient’s privacy at all times. Patient should be covered at all times and only relevant parts of her anatomy exposed.

34. GENERAL & SYSTEMICEXAMINATION BUILT : It can be expressed as average/short stature/tall stature NUTRITION : It can be expressed as Average/good/poor or malnourished/looks obese. Nutrition is clinically assessed by measuring the skinfold thickness between index or middle finger or by callipers . Mid thigh circumference examining the features of vitamin deficiency.

35. HEIGHT : Measured either in centimeter or foot and inches. WEIGHT : Write in kg. Assess overweight or thin/underweight. BMI<18.5-Underweight, 25-29.9 – Overweight, >30-obesity Obesity with menstrual abnormality in young girl may be due to PCOS. Middle aged women with obesity, HTN and diabetes are subjects for corpus cancer syndrome.

36. EDEMA: write as present or absent, pitting or non pitting edema like myxedema . Primary sites to examine: Just above the Medial malleolus elicited by pressing with the tip of right thumb at least for 15 seconds. Anterior surface of lower third of shin bones. The dorsum of foot.

37. ANEMIA : present or absent – mild,moderate or severe. Primary site to see – lower palpebral conjunctiva – retract both the lower eyelids at a time and tell the patient to look upward. Other sites – dorsum and tip of the tongue, soft palate,nail beds, palm and soles,skin . Clinically , anaemia is categorized as mild moderate and severe and may not be associated with laboratory findings always. Mild : 10-10.9gm% Moderate : 7 to < 9.9 gm % Severe : < 7 gm % Very severe : 4 gm % Common causes of anaemia – IDA, AUB, repeated pregnancy, bleeding piles, thalassemia and hook worm infestation. In case of aub status of pallor reflects severity of bleeding.

38. CYANOSIS : JAUNDICE : expressed as present or absent . Sites to detect : Upper bulbar conjunctiva , under surface of tongue , soft palate , sole and palm , skin. CLUBBING : TONGUE,TEETH,GUM AND TONSILS : The mouth is examined for any features of malnutrition like glossitis , stomatitis, presence of any specific focus like tonsillitis and caries teeth.

39. SECONDARY SEXUAL CHARACTERS The important physical changes evident during puberty are breast , pubic and axillary hair growth , growth in height and menstruation. The most common order is beginning of the growth spurt , breast budding( THELARCHE ),pubic and axillary hair growth( ADRENARCHE & PUBARCHE ),Peak growth in height , Menstruation( MENARCHE )

40. TANNER STAGING

41. EXAMINATION OF FACIES AND SKIN : Excessive acne over face , excessive hair growth over face and other areas( hirsutism ), acanthosis nigricans are features of androgen excess commonly pcos . NECK GLANDS : Neck is examined for presence of any enlarged gland . LEG VEINS : Notes the presence of tortuosity of veins ,varicose veins or presence of any pigmentation or ulcer . PULSE,RR,TEMPERATURE,BLOOD PRESSURE

42. SYSTEMIC EXAMINATION CARDIOVASCULAR SYSTEM : Palpation of precordium and ausculation of heart are done in different areas. RESPIRATORY SYSTEM: GASTROINTESTINAL SYSTEM : liver and spleen are palpated routinely for any enlargement and tenderness.

43. GYNECOLOGICAL EXAMINATION Breast Examination Self Breast Examination (SBE) – is an examination performed by the patients herself to detect abnormalities . Clinical Breast Examination (CBE) – completed by clinical health care proffesional to detect any lump or mass in the breast as an initial investigation which may be followed by a mammography. ACOG (2014b) recommends that woman receive a CBE every 1-3yr between ages 20 & 39.

44. Initially during CBE , the breasts are viewed as a woman sits on the table’s edge with hands placed at her hips and with pectoralis muscles fixed. this position enhances to visualise asymmetry. Additional arm positions, such as placing arms above the head Breast skin is inspected for breast erythema; retraction; scaling especially over the nipple; and edema, which is termed peau d’orange change . The breast and axilla are also observed for contour symmetry. With the patient leaning slightly forward, breasts are visually inspected for breast contour asymmetry or skin dimpling.

45. Following inspection, axillary, supraclavicular, and infraclavicular lymph nodes are palpated most easily with a woman seated and her arm supported by the examiner The axilla is bounded by the pectoralis major muscle ventrally and the latissimus dorsi muscle dorsally. Lymph nodes are detected as the examiner’s hand glides from high to low in the axilla Momentarily compresses nodes against the lateral chest wall. In a thin patient, one or more normal, mobile lymph nodes less than 1 cm in diameter may commonly be appreciated The first lymph node to become involved with breast cancer metastasis (the sentinel node) is nearly always located just behind the midportion of the pectoralis major muscle belly.

46. breast palpation is completed with a woman supine and with one hand above her head to stretch breast tissue across the chest wall Examination includes breast tissue bounded by the clavicle, sternal border, inframammary crease, and midaxillary line.

47. Breast palpation within this pentagonal area is approached in a linear fashion. Technique uses the finger pads in a continuous rolling , gliding circular motion

48. During CBE, intentional attempts at nipple discharge expression are not required unless a spontaneous discharge has been described by the patient. If abnormal breast findings are noted, they are described by their location in the right or left breast, clock position, distance from the areola, and size. Fig. 5 : Palpation through several depths at each point asking the linear path

49. Abdominal examination Prerequisites Bladder should be empty . The only exception to the procedure is the presence of history suggestive of stress incontinence. If history is suggestive of chronic retention of urine, catheterization should be done taking aseptic precautions, using sterile simple rubber catheter The patient has to lie flat on the table with the thighs slightly flexed and abducted to make the abdominal muscles relaxed The physician usually prefers to stand on the right side Presence of a chaperone (a female) for the support of the patient and the physician.

50. Inspection: Contour of abdomen,condition of skin,condition of umblicus,presence of any scar and its description ,presence of any lump or fullness of abdomen, presence of sites of hernia-cough impulse if any,enlarged inguinal lymph nodes. The skin condition of the abdomen— presence of old scar, striae , prominent veins or eversion of the umbilicus is to be noted. By asking the patient to strain, one can elicit either incisional hernia or divarication of the rectus abdominis muscles. In intestinal obstruction, the abdomen is uniformly distended. In pelvic peritonitis, the lower abdomen is only distended with diminished inspiratory movements. In ascites, one can find fullness only in the flanks with the center remaining flat. A huge pelvic tumor is more prominent in the hypogastrium situated either centrally or to one side .

51. Palpation: The palpation should be done with the flat of the hand gently rather than the tips of the fingers. If rigidity of the abdominal muscles is encountered, it may be due to high tension or due to muscle guard . If a mass is felt in the lower abdomen, its location, size , consistency , feel, surface, mobility from side to side and from above to down, and margins are to be noted. Whether the lower border of the mass can be reached or not should be elicited. In general, lower border cannot be reached in pelvic tumor , but in ovarian tumor with a long pedicle one can go below the lower pole. If the tumor is cystic and huge, one can exhibit a fluid thrill felt with a flat hand placed on one side of the tumor when the cyst is tapped on the other side of the tumor with the other hand. Whether a mass is felt or not, routine palpation of the viscera (for any organomegaly ) includes—liver, spleen, cecum and appendix, pelvic colon, gallbladder and kidneys.

52. 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. In presence of ascites, the flanks will be dull on percussion and the shifting dullness, if elicited, confirms the diagnosis of free fluid in the peritoneal cavity. It is, however, mandatory to elicit presence of free fluid in the peritoneal cavity in every cases of pelvic tumor . Fluid thrill is present in huge ascites and is also present in large ovarian cyst and in encysted fluid.

53. DEMONSTRATION OF SHIFTING DULLNESS: In supine position, percuss from midline out to the flanks. Any change from resonant to dull is noted along with areas of dullness and resonance. Finger on site of dullness is kept and patient is asked to turn on to her side and a pause of 10-30 seconds is given. Then again percussion is done. If the dull and tympanic areas are reversed “SHIFTING DULLNESS” is said to be positive.

54. DEMONSTRATION OF FLUID THRILL: It is done when abdomen is tensely distended.The palm of left hand flat is placed against the left side of the patient’s abdomen.The patient or an assistant is asked to place of the edge of the hand on the midline of abdomen.THE RIGHT SIDE OF ABDOMEN IS FLICKED BY A FINGER OF RIGHT HAND ,IF A RIPPLE IS FELT AGAINST LEFT HAND “FLUID THRILL”,IS SAID TO BE PRESENT.

55. Auscultation: Ordinarily, auscultation reveals only the intestinal sounds. Hypoactive bowel sounds are found in paralytic ileus, hyperactive bowel sounds may be due to intestinal obstruction. The uterine souffle may be heard over a pregnant uterus or vascular fibroid, which is synchronous with the patient’s pulse. If the tumor is of pregnant uterine origin, fetal heart sound can be heard beyond 24 weeks.

56. INTRODUCTION Gynecological examination confirms the presesnce of pathology suspected from the gynecological history. Always explain the patient the need and nature of the proposed examination. Obtain informed verbal consent. The examiner should accompany another female and examination done in a private setting respecting patients privacy at all times and only relevant parts of her anatomy should be exposed.

57. PELVIC EXAMINATION Inspection of external genitalia. Vaginal examination -Inspection of cervix and vaginal walls -Palpation of the vagina and vaginal cervix by digital examination. -bimanual examination of the pelvic organs. -rectal examination - rectovaginal examination.

58. PREREQUISITES The patients bladder must be empty.the exception being a case of stress incontinence. To examine a minor or unmarried,a consent from the parent or guardien is required. Lower bowel[rectum and pelvic colon] should be preferably empty. A light source should be available. A sterile gloves , lubricant,speulum,sponge holding forceps and swabs are required.

59. POSITION OF THE PATIENT The patient commonly examined in dorsal position,with the knees flexed and thighs abducted.this position gives better view of the external genitalia and bimanual examination can be effectively peformed . sims \lateral position Lithotomy position

60. Dorsal position

61. Lithotomy position

62. Inspection of the vulva Assess all structures frm anterior to posterior, * mons pubis-pubic hair distribution[inverse triangle] *labia majora -lateral to the intriotus covered with pubic hair,they meet anteriorly as mons pubis. *labia minora -medial to labia majora with no hair covering,they meet anteriorly to cover the clitoris. * perinium -area between the fourchette and the anus,inspect for lesions,scars and old third degree perineal tears.

63. In older women-ask to cough to demonstrate urinary incontinence or utero vaginal prolapse . Lastly look for hemarrhoids,anal fissure,anal fistula .

64. Cusco’s

65. Cusco’s speculum

66. Indications – -self retaining double bladed vaginal speculum. -used in opd for routine examination.because of limited opening only few procedures like , *Pap smear *insertion and removal of copper T can be done. * colposcopy *to perform minor procedure like punch biopsy.

67. Sim’s speculum

68. Indications- -used for inspection of vagina and cervix in the OPD.it retracts posterior vaginal wall. -used in gynae OPD for, *taking pap smear *insertion and removal of copper T * colposcopy *taking swabs * hysterosalpingography

69. Speculum examination preferably done prior to bimanual examination. The advantages are, -cervical scrape cytology and endocervical sampling can be taken as screening in the same sitting. -cervical or vaginal discharge can be taken for bacteriological examination.

70. The cervix is best visualized with the cusco variety.but while the vaginal fornices can be visualized by cusco ,the anterior vaginal wall is to be visualized by sim’s variety. Sim’s speculum is advantageous in cases of genital prolapse .

71. Pap smear

72. RECTAL EXAMINATION Rectal examination can be done in isolation or as an adjunct to vaginal examination . Indications for Rectal examination, -children or in adult female. -painful vaginal examination. -carcinoma of cervix -to corrabrate the findings felt in the pouch of douglas by bimanual vaginal examination…….

73. ….. - atresia of vagina -patients having rectal symptoms. -to diagnose rectocoele and differentiate it from enterocoele .

74. Rectovaginal examination The procedure consists of introducing the index finger in the vagina and the middle finger in the rectum. The examination may help to determine whether the lesion is in the bowel or between the rectum and vagina like , any thickening of uterosacral ligaments or presence of endometriotic lesions are noted. This is a special help to differentiate a growth arising from the ovary or rectum.

75. THANK YOU.