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Gynaecological History and Physical Examination
Don’t forget that a gynaecological patient is still an entire person!
Taking the History
Opening statement: introduce yourself and commence inquiry which includes the
patient’s name, age and reason for consultation or presentation
eg. Mrs X is a 50 year old woman, who presents with a “sensation of something
coming down” for 5 years.
- Details of presenting complaint
- General gynaecology history (ask the following if appropriate ie don’t ask
a 30 year old woman about postmenopausal bleeding).
- Menarche/menopause
- Premenstrual – details
- Menses
- frequency, duration, amount, pain
- Abnormal bleeding
- Intermenstrual bleeding – details
- Postcoital bleeding – details
- Postmenopausal bleeding - details
- Vaginal discharge – details
- Dyspareunia – superficial or deep
- Sexual history
- Previous gynaecological problems – STIs, endometriosis, infertility, surgery,
polycystic ovarian disease
- Contraception
- Urinary symptoms – frequency, nocturia, dysuria, incontinence, haematuria
- Bowel symptoms – Bleeding, fecal incontinence, bowel habits, mucus in stool,
difficulty emptying bowel
- Papanicolou smear history, date and results of last cercvical smear
- Mammogram history if appropriate
- Previous obstetric history - details
- Previous medical/surgical/psychiatric history
- Medications
Doses and times of administration
- Allergies
- Social history
Marital status and supports/Employment
Smoking/Alcohol/Other drugs
- Family history
- Systems enquiry
- Summarizing the patient’s presenting complaint and past medical history
relevant to this specific complaint. (eg. Mrs X is a 50 year old woman,
who presents with symptoms suggestive of uterovaginal prolapse. She is a grandmultipara,
smokes 20 cigarretes a day, has chronic bronchitis and is currently on a weight
reducing program.
Performing the Physical Examination
- General inspection (demeanour; pallor; scars; tattoos; rashes)
- Observations (BP, RR, HR)
- Lymph nodes and thyroid examination
- CVS examination
- Respiratory system examination
- Perform a breast exam
- Perform a pelvic exam
- Perform a Pap smear
Summarize the history and examination findings and a proposal of management
plan - eg. Mrs X is a healthy 50 year old woman who has significant utero-vaginal
prolapse without urinary disturbance. Beyond a weight of 80 kg and smoking
history the patient’s physical exam is normal. The prolapse significantly interferes
with her lifestyle. She is motivated to stop smoking and losing weight. I
would propose vaginal surgical repair once she has reached her target weight
of 70Kg.
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