Gynecological history and

Physical examination

OB/GYN Hospital, Fudan University, Shanghai, China

Lu Yuan
 Medical history collecting and writing

 Physical examination
 Authenticity, systematicness and integrity of Medical
history, largely depend on the interrogation methods
and skills

Good communication is necessary for the

assessment of patient's condition and
treatment

communication technique
 consentration
 Knowledge Trustment
 kindness
 Humor?
1.general item 5.Menstruation history
2.Chief complaint 6.Marriage history
3.Present medical History 7.Personal history
4.Past medical history 8.Family history
General Item

Name, Gender, age, nationality,

marriage, occupation, hometown

Adress, time of hospitalization,

history collecting time, history
provider
Complaint

The main symptoms or The duration of symptoms

（using the Professional term: in 20 words)

For example:
 12 weeks menopause, vaginal bleeding for two days, abdominal
pain for one hour

 uterine fibroids found for one month in Gynecological checkup

 G2P0 pregnancy 37 +6 weeks, bloody show for 3 hours

Present Medical History

 Focused on the chief complaint -- occur, evolution,

diagnosis and treatment procedures

 Onset and duration of illness

 The main symptom characteristics
 Causes and incentive
 Accompanying symptoms
 related positive and negative information
 diagnosis and treatment process
 Diet, sleep, body weight, Stool and urine
Past Medical history

previous health condition

general health condition and medical
history
Operation history of trauma, infectious
diseases history, vaccination history,
allergic history, history of blood
transfusion.
systematically review
Menstruation history

 Age of menarche, menstrual cycle,volume, associated

symptoms, LMP/PMP, amenorrhea, menopausal age date
 LMP：Last menstrual period
 PMP：Previous menstrual period

For example:
The female patient, 27 years old, complaint in August
menstruation was late, and previous menstrual date was inJuly
16th. Menarche occurred in junior high, normally 2 days ahead
of each period, much volume in first 2 days, less after,
accompanied by mild back pain.
Marriage history

 marriage history (times of marriage, age of

marriage)
 health condition for husband
 history of giving birth:
Full-term-Premature birth-Abortion-Survival
2-0-1-2
 G2P1:pregnancy 2, birth 1
 birth control mesures
Personal information history

Birth place, previous location

bad habits for cigarette and alcohol

Family history

Parents
cousins，sibling Health conditions
children
 Discussion

how to deal with the garrulous patients

who always deviate from describing health
condition in querying the medical history?

1、 please write a complaint according to the following

information:
 The female patient, 42 years old, complaint in recent 1 years
by the increased amount of menses, accompanying a
backache with fatigue
 The female patient, 35 years old, lower abdominal pain for 2
days recent one month, and leucorrhea has peculiar smell
Discussion

2, please according to the following data to write

present medical condition, to see what is needed for
history collection:

 At the age of 28, amenorrhea for 2 months,

irregular vaginal bleeding
 40 years old, the vulva pruritus, leucorrhea is
abnormal
 At the age of 26, 7+ months of pregnancy, vaginal
bleeding
 Medical history collecting and writing
 Physical examination
physical examination

 symptoms
 general check up
 abdomen examination
 Pelvic examination –gynaecology
examination
The basic requirements of the pelvic examination

 Check carefully, gentle movement

 urine evacuated before check ( urine preserved for
checkup )
 Replace the one-time pad
 Bladder lithotomy position
 To avoid the menstrual period. What should you do
before check, if check is must while bleeding?
 Male doctor to check best with female physician
presence to avoid unnecessary misunderstanding
 step-1

 Vulval inspection

 Vulva development and its hair

distribution
 New biological, skin lesion vulva
 Vaginal vestibule
 Hymen
 The vagina mouth
 vaginal wall and uterine prolapse or not
 step2

 check up by speculum
 Speculum forbidden without
agreement by virgin
 replacement and removal
 step 3

 Vaginal inspection
 deformity: vaginal septum, double
vagina
 new biological, ulcer, cyst or not
 Vaginal discharge is normal, if
necessary, check leucorrhea
routine
 step 4

 Cervical inspection

 Size, color, mouth shape

 bleeding, erosion, gland cyst,
polyps
 Cervical tube has hemorrhages or
exudates or not
 Cervical smear
 Cervical scraping smear
 step 5

 Bimanual examination
 Check with two fingers or
one finger into the vagina,
while the other hand in the
abdomen to help checking
 Vaginal, cervical,
endometrial, attachment,
palace and pelvic wall
step 6
 Trimanual examination
• Rectal, vaginal, abdominal
examination

 Rectal - abdominal diagnosis:

• index finger into the rectum, with
the other hand in the abdomen
helping check
• Asexual life history, vaginal atresia
or other reasons can not be
performed bimanual examination.
Check up record

 The vulva: development, production type.

 Vaginal: Patency, mucosa, secretions
 Cervical: size, hardness, erosion, contact bleeding,
lifting pain
 Uterine body: location, size, texture, motion,
tenderness
 Bilateral accessory: mass, size, texture, motion,
tenderness, and relationship between uterus and
pelvic wall
 Gynecological examination evaluation standard ( out
of 100 points )

1、Examination of vulva (5 points)

2、Speculum removal (5 points)
3、speculum with lubricant (5points)
4、Speculum two leaf close up (5 pints)
5、Along the posterior wall to insert vagina speculum into the
vagina, gradually flattening, open two leaves, gentle action ( 10
points)
6、 Exposure of the vaginal wall, cervical and fornix ( 10 points)

 Examination of the vaginal wall mucosa color, elastic

 The amount of vaginal discharge, character, color, smell
 Cervical size, mouth shape, erosion and polyps or not
Gynecological examination evaluation standard ( out of
100 points )

7. Speculum removal (5 points)

8. wearing sterile gloves ( 5 points)
9. the index finger, middle finger stick lubricant
( 5 points)
10.examination of vaginal, cervical, posterior
fornix ( 15 points)
11.bimanual examination ( 20 points)
12.the finger out of the vagina, disposable
gloves, the patient is asked to get dressed
( 10 points)
The four step of obstetric palpation
Four step palpation evaluation standard ( out of 100 points )

1. The first step: check while facing the patient, hands at the
fundus of uterus, to examine uterine fundal height and shape
( 20 points)
2. The second step: check while facing the patient, his hands
placed on their abdomen from side to side, one fixed, and the
other hand gently press, alternating to tell the fetal back and
fetal limb position ( 20 points)
3. The third step: check while facing the patient, the right hand is
placed above the pregnant woman’s pubic symphysis, thumb
and the remaining four fingers apart, holding the present of
moving around, confirm the present ( 30 points)
4. The fourth step: check facing the patients’ foot, both hands
are placed in the two sides of the present, deep press near the
pelvis downward direction, to review the correction of the
diagnosis, and determine its engagement degree ( 30 points)
Assistant checkup

ordinary test
special test
special checkup
 Date、serial number