How to Take a Good Gynecological History & Performing a Thorough Clinical Examination

HISTORY:

Demographical Details/Personal Profile:

1. Name

2. Age

3. Education

4. Occupation

5. Marital Status (if married, for how long? )

6. Residence

7. Date (and time) of Admission

8. Mode of Admission

Presenting Complaints:

Common complaints encountered in a gynecological patient are

1. Abnormal Menstruation

a. Pattern (Regular/Irregular)

b. Amount of blood loss

c. Passage of blood clots

d. Duration of menstruation

e. Intermenstrual Bleeding

f. Post coital Bleeding

2. Bleeding in early pregnancy i.e. before 24 weeks of gestation (Abortion/Miscarriage)

3. Something coming out of vagina

4. Pelvic Mass

5. Vaginal Discharge – amount, colour, odour, presence of blood, relation to periods

6. Pelvic pain – site, nature and relation to periods. Anything that aggravates or relieves the pain

History of Present Illness:

Depending upon the presenting complaint, following questions may be relevant to ask

1. Onset

2. Duration

3. Intensity/Severity

4. Aggravation and relieving factors

5. 5. Associated features

Menstrual History:

1. Age of menarche

2. Cycle Regular or Irregular

3. Duration of Cycle

4. Quantity of Blood loss

5. Dysmenorrhoea

6. Intermenstrual Bleeding

7. Post coital Bleeding

8. LMP

Past Gynecological History:

1. Any previous gynecological problems

2. Any treatment for the same

3. Cervical Swab/ Cervical Smear

Past Obstetrical History:

1. Number of children

2. Ages of all children

3. Mode of deliveries of all children

4. Gestational age of all children at the time of delivery (Term/Preterm etc.) + Presence state of health

5. Number of miscarriages and duration of gestation at those

6. Termination of pregnancy/pregnancies, At what gestation? For what reason?

Sexual and Contraceptive History:

1. Age at first intercouse

2. Coital freuency

3. Dyspareunia

4. Any coital difficulty

5. Number of sexual partners

6. Number of sexual partners of the patient’s partner/husband

7. Use of contraception? Type of contraception used?

Past Medical History:

(Please refer to clinical methods of Internal Medicine for details.)

Past Surgical History:

(Please refer to clinical methods of Internal Medicine for details.)

Systemic Inquiry:

From CVS, CNS, RS, GIT, GUT & MSK

(Please refer to clinical methods of Internal Medicine for details.)

Family History:

About Infectious diseases, IHD, HTN, DM, Multiple Pregnancy, Gynecological and other malignancies

(Please refer to clinical methods of Internal Medicine for details.)

Social/ Socioeconomic/ Biosocial History:

1. Place of living

2. Type of family

3. Monthly Income

Personal History:

(Please refer to clinical methods of Internal Medicine for details.)

Drug History:

(Please refer to clinical methods of Internal Medicine for details.)

Treatment History:

(Please refer to clinical methods of Internal Medicine for details.)

Examination:

General Physical Examination:

(Please refer to clinical methods of Internal Medicine for details.)

Systemic Examination:

Abdominal (Please refer to clinical methods of Internal Medicine for details.)

CNS (Please refer to clinical methods of Internal Medicine for details.)

CVS (Please refer to clinical methods of Internal Medicine for details.)

RS (Please refer to clinical methods of Internal Medicine for details.)

Pelvic Examination: (Not expected from Final Year students.)

(Ensure Adequate Privacy)

1. Inspection

a. Hair Distribution

b. Labial Appearance

c. Episiotomy Scar etc.

d. Stress incontinence

e. Vaginal Discharge

2. Speculum Examination

a. Inspection of vaginal walls (Atrophic/Healthy/Hyperemic/Growth/Ulcers/Polypi etc.)

b. Appearance of cervix (Ectopy/Suspicious Polypi)

c. Vaginal discharge

3. Bimanual Examination/Palpation

a. Consistency of cervix

b. Cervical os

c. Uterine consistency, size, shape and mobility

d. Uterus retroverted or anteverted

e. Adnexal Mass

f. Adnexal Tenderness

g. Pouch of Douglas

Provisional/Working Diagnosis:

Differential Diagnosis (es):

Investigations:

a. Routine

b. Specific

Definite Diagnosis:

Plan of Management:

SUMMARY: