Shri Gujarati Samaj Indore

SKRP Gujarati Homoeopathic Medical College Hospital & Research centreGuided BY : SUBMITTED

BY :DEEPTI GAUTAM3RD PROFF

THE GYNAECOLOGICAL EXAMINATION AND PELVIC AID DIAGNOSIS

CONTENTS

IntroductionGynecological historyGeneral examinationBreast examinationAbdominal examinationPelvic examination - Digital

and speculum examinationInvestigations

INTRODUCTION

Gynecological history coupled with a systemic examination would help in arriving at the correct diagnosis.

A good history taking ,alone can give a positive diagnosis without any physical examination.

•The examination should, in fact proceed with the provisional diagnosis in mind.•Patients privacy should be respected always .•A brief outline of history taking is given below:

GYNAECOLOGIACAL HISTORY

History should be taken in details.

If multiple symptoms are present, their chronological appearances are to be noted.

Enquiry should be made about the bowel habits and urinary troubles if any.

GYNAECOLOGIACAL HISTORY

MENSTRUAL HISTORY OBSTRETIC HISTORY PAST MEDICAL HISTORY PAST SURGICAL HISTORY FAMILY HISTORY PERSONAL HISTORY

MENSTRUAL HISTORY

Inquiry should be made about: First menarche(age of onset of first

menstrual period) Regularity of cycle Duration of period Length of the cycle Amount of bleeding excess is indicated

by clots and number of pads used. First day of last menstrual period(LMP)

OBSTRETIC HISTORY

If the patient had been previously pregnant then details should be noted.

Some times, the complaints may be related due to the pregnancy or lactation complications.

OBSTRETIC HISTORY

The details should be noted in following way

No. Date

Year &events

Pregnancy details

Labour details

Method of delivery

puerperium

Baby wt &sex birth asphyxia. duration of breast feeding, contraception

1

2

PAST MEDICAL HISTORY

The following disorder should be noted

SystemicMetabolicEndocrinal(diabetes, hepatitis,

hypertension)Sexual transmitted disorder

PAST SURGICAL HISTORY

This includesGeneral Obstetrical Gynecological surgeryNature of operation Bleeding or clotting complicationPost operative care Any histopathologiacal disorder

FAMILY HISTORY

It is of occasional value .Malignancy of breast,ovary,colon

are often related.Tubercular infection in family

can also give clue about pelvic tuberculosis

PERSONAL HISTORY

Occupation Marital status : widow, single,

married. If married then sexual history

should be taken.Contraceptive practice, if any,

should also be inquired.

EXAMINATION

GUIDELINES

Gynecological examination confirms presence of pathology suspected from the gynecological history.

Always explain to the patient 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.

GENERAL AND SYSTEMIC EXAMINATION

BUILT: to obese or too thin. May be due to any endocrinopathy.

NUTRTION: average/ poorSTATURE: including development

of secondary sex characters.PALLOR JAUNDICE

OEDEMA OF LEGSTEETH GUMS AND TONSILSNECK: palpation of thyroid gland

and left Supraclavicular glands CARDIOVASCULAR AND

RESPIRATION SYSTEMS: any abnormality if present

PULSEBLOOD PRESSURE

GYNAECOLOGICAL EXAMINATION

BREAST EXAMINATIONABDOMINAL EXAMINATIONPELVIC EXAMINATION

BREAST EXAMINATION

Inspection with arms by her side

Inspection with arms Raised above Inspection with Hands at waist

Palpation of axillary node Palpation of Supraclavicular nodePalpation of Other half of breast

BREAST EXAMINATION

It should be routine examination in women above the age of 30

POSITION: patient reclining at 45 degrees with arms at the sides

INSPECTION – positions at rest, arms above head, on hips

1) Development and symmetry of breasts and nipples.

2) Reddening of skin, ulceration or dimpling (peau d'orange)

3) Retraction of nipple (CA breast) 4) Nipple discharge- blood, serous or

milky

PALPATION- palpate systematically for lumps with the flat part of the fingers, through all 4 quadrants. If present, describe the characteristics of the lump- location, size, shape, surface, edge, consistency and mobility in relation to deep and superficial structures.

Palpate the axillae for lymph nodes – describe if present

ABDOMINAL EXAMINATION

PREREQUISITE Bladder should be empty, if there is

history of chronic retention of urine, then do catheterisation.

The patient is to lie flat on table with thigh slightly flexed and abducted to make abdominal muscle relaxed.

The physician should stand on right side

Presence of female for the support of the patient

STEPS

INSPECTION: Assess for distension, scars (operative, traumatic or scarification), distended veins, striae, pubic hair distribution.

PALPATION: Palpate the abdomen systematically in all 9 regions

1) Superficial palpation- assess for tenderness, guarding and rebound tenderness

2) Deep palpation- assess any enlargement of intra-abdominal organs (uterus, liver, spleen etc) and for any abnormal masses.

Describe any abnormal mass in terms of:

SIZE, SHAPE POSITION- MOBILITY- movable or fixed SURFACE - e.g. smooth or nodular CONSISTENCY - e.g. solid or cystic TENDERNESS (pain on palpation)

PERCUSSION: A pelvic tumor is usually dull and

resonance on flanks Assess for ascites using shifting

dullness and fluid thrill AUSCULTATION: Listen for bowel

sounds or for fetal heart rate in pregnancy.

Uterine soufflé can also be heard in pregnancy.

PELVIC EXAMINATION

This includes Inspection of external genitaliaVaginal examination

Inspection and palpation of cervix and vagina walls

Rectal examinationRectovaginal examination

Positions of patient during examination

Sims position Dorsal position Lithotomy position

Sims position

Dorsal position

Lithotomy position

INSPECTION OF VULVA

To note any : Anatomical abnormality starting form

pubic hair, clitoris, labia and perineum. Palpable pathology External urethral meatus and opening of

bartholin duct and character of hymen. To ask the patient to strain to elicit:

To see stress incontinence Genital prolapse

Lastly look for hemorrhoids

VAGINAL EXAMINATION

INSPECTION OF VAGINA AND CERVIX

Speculum examination

Digital examination

Bimanual examination

SPECULUM EXAMINATION

Most Preferably used.Advantages are:Cervical scrape cytology and

endocervical sampling can be taken for screening.

Cervical or vaginal discharge can be taken for bacteriological examination.

TWO TYPE OF SPECULUM IS USED

Sims's speculum Cusco’s valve

In dorsal position Cusco's valve is used, while in lateral – sim’s speculum.

Cervix is best seen by Cusco's valve

Vaginal fornices can only be seen by Cusco's valve while anterior wall of vagina can be seen by sim’s speculum.

DIGITAL EXAMINATION

Done by using gloved index finger lubricated with sterile lubricant.

In virgins done under anesthesia.To note

Palpation of any labial swelling Pressing of urethra from above down

ward to see any discharge escaping out.

Palpation of vaginal walls to detect any abnormality

Palpation of vaginal portion of cervix To note Direction-in anteroverted uterus ant. lip is

first felt & in retroverted position external-os or post. lip is felt.

Station-external-os is at level of ischial spine Texture- in nonpregnant stage firm. Shape- conical in multipara and cylindrical in

nullipara. Ext.os –smooth and round in nullipara and

dilated in parous Movement-painful or not Whether it bleeds or not

BIMANUAL EXAMINATION

Done by using gloved index finger lubricated with sterile lubricant.

Gloved right index and middle finger is inserted in to the vagina,if intortius is narrower then only one finger is used.

The left hand is placed on the hypogastrium well abdomen above the symphysis pubis so that the organs can be palpated.

BIMANUAL EXAMINATION

PALPATION OF UTERUSPALPATION OF UTERINE

APPENDAGESPOUCH OF DOUGLAS

PALPATION OF UTERUS

Note its position size shape consistency

and mobility Normally the uterus is anteverted,

pear shaped firm, freely mobile in al directions.

PALPATION OF UTERUS

PALPATION OF UTERUS

PALPATION OF UTERINE APPENDAGES

Normally uterine tube cannot be palpated.

Normal Ovary cannot be palpated. If palpated, it is mobile and sensitive

to manual pressure.

PALPATION OF UTERINE APPENDAGES

POUCH OF DOUGLAS

Normally faecal mass in rectosigmoid and the body of retroverted uterus is felt.

Indications of mass felt of bimanual examination

Uterine tumor: Uterus is not separated from mass Movements of mass felt per

abdominally transmitted to the cervix.

Uterine tumor:

Adnexal mass: uterus is separated from mass Movements of mass are not

transmitted to the cervix.

RECTAL EXAMINATIONORRECTOVAGINAL EXAMINATION

RECTAL EXAMINATION

Indication for rectal examination: Children or in adult virgins. Painful vaginal examination Ca of cervix Abnormal findings in pouch of

Douglas during bimanual examination

Artesia of vagina Patient having rectal symptoms

RECTAL EXAMINATION

RECTOVAGINAL EXAMINATION

In this procedure, gloved index finger is introduced n vagina and middle finger is introduced in rectum

Helps in determining whether the lesion is in bowel or between rectum and vagina .

RECTOVAGINAL EXAMINATION

DIAGNOSTIC PROCEDURE

Blood values Urine Urethral discharge Vaginal or cervical discharge: done

by Cusco's bivalve speculum

BLOOD VALUES

Hemoglobin estimation: in cases of excessive bleeding.

TLC & DLC, ESR Platelet count in cases of puberty

menorrhagia.

:diagnosis of pelvic inflammation

URINE EXAMINATION

For the presence of protein sugar pus cell casts are done .

In the presence of excessive of vaginal discharge midstream urine is taken

Culture &drug sensitivity test: Midstream collection Catheter collection Suprapubic bladder puncture

EXAMINATION OF CERVICAL MUCUS

Bacteriological study: Cusco's bivalve speculum is inserted

without lubricant sample is taken via sterile cotton sterile swab and sent for culture.

EXAMINATION OF CERVICAL MUCUS

Hormonal status: cervical secretion is dependent on

hormones estrogen and progesterone the influence of these hormones helps in detection of time of ovulation.

Normal Ph of cervical mucus during ovulation is about 6.8-7.4.

Fern test

Cervical mucus shows characteristic fern pattern formation.

The ferning disappears completely after 21st day .

Presence of ferning even after the 21st day indicates anovulation and its absence gives evidence of ovulation.

INVESTIGATIONs

Colposcopy

X-ray Ct scan Ultrasoun

d MRI

X ray

Uses Can be helpful in locating IUCDs,

benign tumors etc.

Ct scan

Bilateral ovarian cystic masses

INVESTIGATIONs

ENDOSCOPY

Culdocentesis Laparoscopy Hysteroscopy Salpingoscopy

COLPOSCOPY

Done by colposcope. Use: magnify the surface

epithelium of the vaginal part of the cervix including entire transformation zone

COLPOSCOPY

CULDOCENTESIS

Aspiration of peritoneal fluid from pouch of doulas.

LAPAROSCOPY

Visualization of peritoneal cavity by means of a fiber optic endoscope.

HYSTEROSCOPY

Visualization of endometrial cavity by means of a fiber optic telescope

SALAPINGOSCOPY

Visualisation of uterine tubes.FIMBRIA

TELESCOPE

UTERINE TUBE

END OF PRESENTATION

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