1 / 29

Gynecologic History and Physical exam

Gynecologic History and Physical exam. Jonathan Tankel FRCSC FACOG Dept of Obstetrics and Gynecology & Student Health Service, U of A jtankel@ualberta.ca. Gynecolgic History. Remember: This may be the women’s only contact with the health care system

vui
Télécharger la présentation

Gynecologic History and Physical exam

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Gynecologic History and Physical exam Jonathan Tankel FRCSC FACOG Dept of Obstetrics and Gynecology & Student Health Service, U of A jtankel@ualberta.ca

  2. Gynecolgic History • Remember: • This may be the women’s only contact with the health care system • Women vary in their knowledge and comfort level • Sensitivity, non –judgmental • Best to do history prior to patient undressing • Avoid assumptions re sexual activity/orientation • Start with less sensitive questions and work “up” • May very depending on whether routine or problem specific visit

  3. Basic Gynecologic History:Menstrual (28 +/- 7 days) • Main complaint • Menstrual History: • Menarche, regular/irregular – cycle length, “heavy” intermenstrual bleeding, dysmenorrhea • Last period (LMP) and last normal period (LNMP) • Cyclical Molimina/PMS • Postmenopausal: LMP, Hormones (HRT), Bleeding (PMB), Vasomotor symptoms, symptoms of atrophy

  4. Gynecologic History:Sexual • 43% women report some form of sexual dysfunction • Patient will often not offer history unless asked “thought it normal, too embarrassed • Are you sexually active? If not prior? When? • Men, women or both? • Penetrative or not? • Satisfied – frequency and quality? Pain? • Any recent new partner or contacts?

  5. Gynecologic HistoryObstetrical • Number of pregnancies G (gestation),P (birht), PT,T, A • Miscarriages, terminations, ectopic’s • Assisted reproduction • Pregnancies • Date • Type of delivery (Vaginal , Operative: C-section, vacuum, forceps) • Maternal complications ( eg HPT,DM) • Fetal complications (eg IUGR, anomalies, stillbirth) • Current health of kids

  6. Gynecologic History:Contraception • Type, past and current • Side effects • Compliance??? • 48% Pregnancies unplanned in N. America!

  7. Gynecologic History:PAP test • Date of last • History of abnormal’s and follow - up • New guidelines; • 1st up after 3 years of “intimate” sexual activity AND age 21 (nobody should be doing one until they are 21 except under very unusual circumstances) • After 3 normal pap’s AT LEAST 1 year apart in 5 years, every 3 years.

  8. Gynecologic History:Procedures • Type : (eg Endometrial biopsy, laparoscopy, hysteroscopy, D+C) • Date • Diagnosis • Complications .

  9. Gynecologic historyOther gynecologic problems • Infertility – how long, investigations, treatment • Ovarian cysts, type, treatment • Endometriosis • Infections: pelvic, vaginal, vulva • Diagnosis, frequency, treatment • Polycystic Ovary Syndrome (PCOS: 5-10% women)

  10. Other Gynecologic problems cont. • Pelvic pain: acute vs. chronic, location, onset, relation ship to menses, GI, UT, MSK • Urologic – Incontinence, frequency, urge • Prolapse • Vulvovaginal symptoms: discharge, dryness, pain, lesions

  11. Gynecologic History:Must include the rest! • Medical • Surgical • Social • Habits • Medications • Allergies • Family REMEMBER THE WOMAN FOR THE PAP WITH THE MELANOMA! • .

  12. GYNECOLOGIC EXAMINATION • 1st exam depends on history • Newborns • Young girls only if issue suggested • Adolescents/young adults: DON’T need exam to screen for STi (Urine for CT/GC • DO NOT EXAM for Contraception (Guys don’t need testicular exam before using condoms?!)

  13. Gyne. exam • Explain, use pictures to explain if possible • Offer mirror • Educational • Participate • Position: • Dorsal lithotomy traditional • Elevate 30-90 deg better • Comfort, eye contact • PROPER DRAPING

  14. Gyne. Exam continued

  15. Gyne exam continued • Explain in detail • 1 study 1000 women: • Discomfort 37% • Embarrassed 20% • Dislike examiner 7% • Prior problems 5% • MAINTAIN EYE CONTACT • Consent • Often presumed • Best to consent • See SOGC guidelines re exam under GA • Anxiety • Recognize • Reassure • Agree to stop if pain • Patient control

  16. Gyne exam contEquipment • Chaperone: NO universal guidelines, ideal, always offer, both male and female physicians at risk • Light, multiple sizes speculum, Pap “stuff”, swabs for Sti, large cotton swabs, pH paper (good for bacterial vaginosis, +4.5), gloves, lubricant, KOH, drapes

  17. Gyne exam:Breast • Breast : Annual exam recommended over 40 (ACOG) • Breast exam younger women controversial as is Breast self exam (higher chance benign lesions) • Inspect: Supine and sitting, hands above head and on hips • Observe: Contour, symmetry, skin, erythema • Palpate using pads of fingers systematically

  18. Gyne ExamAbdomen • Standard technique: • Inspect ( Mass seen?), skin changes, hernias • Palpate: tenderness, masses, hernias, organomegaly, inguinal nodes • Auscultate • Percussion

  19. Gyne exam:External Genitalia • Inspect: • Hair, skin (IMPORTANT!), labia minora and majora, clitoris, introitas, urethra, perineal body, Bartholin’s and periurethral glands • VESTIBULAR EPITHILIUM touched with dry q-tip to assess for pain (Vestibulodynia or provoked localized vulvodynia)

  20. Gyne examVAGINA • Speculum: • Plastic or Metal • Water or lubricant • Insert straight pointing down • Avoid vestibule if pain! (Can apply downward pressure if not – I don’t!) • Discharge: pH • Ulcerations, cysts, whitening, condylomata • PAP

  21. Gyne exam:Vagina cont

  22. Gyne exam:Vagina cont

  23. Gyne exam continued • PAP testing • See new guideline • Spatula then brush OR “1” device with 5 rotations • Evaluate vag wall relaxation and prolapse by removing top speculum and using bottom ½ • May need to have patient stand

  24. Gyne exam continued:Cervix

  25. Gyne exam:Cervix continued Polyps lead to bleeding, usually are removed

  26. Gyne exam cont:Bimanual • Palpation of Vagina, cervix, uterus, adnexa, cul de sac • If pain syndrome, START with single digit in vagina ONLY • Usually index and middle finger dominant hand OR only index finger • ONLY 60% sensitivity!

  27. Gyne exam:Bimanual continued • Uterus: Assess for size, shape, mobility, position, consistency • Version: Position of uterus relative to axis of vagina. Eg. Anteverted, reteroverted • Flexion: Position of uterine fundus relative to the axis of the cervix eg; anteflexed, reteroflexed. • Adnexa: Prominence, size of ovaries, usually tender, should NOT be palpable post menopause. Difficult even with experience • Obesity a limiting factor • Nodularity post cul de sac, tenderness • Motion tenderness: NOT SPECIFIC

  28. Gyne exam:Rectovaginal exam • Allows palpation of post cul de sac (Douglas) & Uterosacral ligaments (and uterus/adnexa) • POOR sensitivity and PPV (poor predictive value) • Not routine, do in high suspicion endometriosis, older (? > 50) • Also assesses rectal lesions, Occult blood, hemorrhoids, sphincter

  29. Gyne exam:Documentation • 6 elements of good record keeping: • Accuracy • Objectivity • Legibility • Timeliness • Comprehensiveness • Absence of alterations

More Related