History and examination

Published on 09/03/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

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Chapter 1 History and examination

History

The gynaecological history and examination are a modification of standardised history taking designed for the efficient elucidation of the presenting problem, concluding with a provisional or differential diagnosis and a plan for further management. This guide to taking a gynaecological history may need to be modified, depending on the presenting complaint:

• name and age

• presenting complaint

• menstrual history

• age of menarche/menopause

• date of last menstrual period

• length of menstruation and cycle

• frequency/regularity of cycles

• menstrual loss, presence of clots or flooding

• duration of dysmenorrhoea and its relationship to periods

• abnormal bleeding

• intermenstrual

• postmenopausal

• abnormal discharge

• colour, pruritus, offensive odour

• cervical cytology

• date of last examination and result

• sexual history

• dyspareunia (superficial, deep, related to menstruation)

• contraception

• previous sexually transmitted diseases

• hormonal therapy

• oral or injectable or intrauterine contraceptives

• hormone replacement therapy

• menopausal symptoms

• onset, duration, nature, site

• relationship to menstrual cycles

• symptoms of prolapse, such as an uncomfortable lump in the vagina

• urinary problems

• incontinence (stress or urge)

• nocturia, frequency, dysuria

• other systems review

• past obstetric and gynaecological history

• past medical and surgical history

• social history

• cigarette smoking and alcohol intake

• medications, other drug use, allergies

Examination

Examination always begins with inspection, then palpation, followed by percussion and auscultation.

General

• appearance, colour

• blood pressure, pulse

• breast examination

• presence of lymphadenopathy

• abdominal examination

Genital examination

• inspection of the external genitalia, urethral meatus

• evidence of oestrogen deficiency, prolapse, unusual masses, ulcers

• speculum: inspection of the vagina and cervix; checking for presence of a discharge; taking specimens for cervical cytology and microbiological swabs; using Sims’ speculum to assess uterovaginal prolapse

• assessing for urinary incontinence with coughing and prolapse reduced

• bimanual examination to assess: uterine size, shape, ante/retroversion, mobility, tenderness; cervical motion pain; adnexal tenderness, masses; pelvic masses and their relationship to the uterus (e.g. separate from uterus, moving with uterus); uterosacral ligament tenderness, presence of nodules; pouch of Douglas (presence of tumour nodules); rectovaginal septum

Conclusion

• summary of history and clinical findings

• provisional diagnosis, further investigations and management

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Examination Obstetrics _ Gynaecology