Case 1 History & PE

CASE 01: HISTORY & PHYSICAL EXAM
First Check-up: Complete physical examination

nd
2 Check-up: more focus on GYN.
4. OB HISTORY
OB VS GYN  E.g. 8-0-2-6  Birth weight of the babies: Bigger 
 OB - pregnant woman Likelihood to have Pelvic organ prolapse
 Gyne - Non-pregnant woman, diseases of the
reproductive system 5. SEXUAL HISTORY
 First sexual contact, no of partners (STID), what kind of
HISTORY TAKING partners? Post-coital bleeding?
 Dyspareunia (Sig: ENDOMETRIOSIS,
1. GENERAL DATA:  Infertility (how often do you have contact?)
Obstetrical Score: GP TPAL
 Gravidity - # of times she got pregnant, 6. FAMILY HISTORY - history of malignancy, diabetes, pox
 Parity - # of pregnancies that have reach the age of infections.
viability
 Full Term (Full Term 38 - 42 weeks) 7. PMH
 Premature (Before 37 weeks)  E.g. had prior appendectomy --> factor with infertility (may
 Abortion (Below 20 weeks) develop adhesions) block the fallopian tubes,
E.g. ectopic pregnancy, gestational trophoblastic  E.g. several operations in colon --> tumor in uterus --> post-
pregnancy, Hydatidiform mole, Incomplete abortion operative adhesions, easily bleeds before operation
 Living (clearance from hematologist,
Significance of GP score: the more children, the higher risk for 8. ROS
Pelvic Organ Prolapse.
PHYSICAL EXAMINATION
2. CHIEF COMPLAINT
What are the symptoms applicable? 1. BREAST EXAMINATION
PELVIC PAIN Why is it part of Gynecology?
 Onset, location, severity, timing (reference to menses:  Recall Pediatrics, pubertal developments is ushered initially
time about to menstruate or unrelated to the cycle), by breast development, in which there would be a
quality (spasmodic, constant), duration & radiation. transition of childhood to adolescence when the girls start
This may be associated with urinary symptoms. to have breast budding.
 Breast will be under the influence of ovarian hormones, so
VAGINAL BLEEDING it’s only when the ovaries start to be active that will start
 Menstrual history: Menarche (first time), interval the breast development. So when we go to Congenital
(succeeding menses how long did it last), pads used anomalies, when we try to examine whether the woman
(how much menstrual discharge) has ovaries or not, we look at the breast because the breast
is a REFLECTION of the function of the OVARIES
 Menstrual Scoring: Always count from day 1 to day 1  Hallmark of PUBERTY  ONSET of menarche
of the next cycle  Also note the difference on the effects of the hormones on
o Menstrual Period: Apr 23  May 20  Jun 5 changes of the breast depending on the cycle
o 8 (Apr D23 to 30) + 20 (May) = 28 days cycle
 NORMAL Breast changes:
o 12 (May: D20 to D31) + 5 (Jun) = 17 days   Just before cycle: more fuller, more tender, more engorged
AUB (Abn Uterine Bleeding - deviation from (peak of progesterone and estrogen)
the normal cycling of the woman)  Right after menses: breast softer, non-tender
o Q: How to differentiate irregular
menstruation from AUB? Need to trace back When is it ideal to perform? RIGHT AFTER MENSES
menarche & interval
What to do? INSPECTION & PALPATION
VAGINAL DISCHARGE INSPECTION
 Lower genital tract infection: vulva, vagina, cervix  Symmetry (can be asymmetrical due to muscle
 Quality, onset (how long: may tell the gravity of the development from exercise)
problem), what kind?, description?, accompanying  Nipple: discharge, retraction
symptoms (usually pruritis vulvae)  Skin: Peau d’orange, flattening, dimpling, erythema, edema
MASSES: PALPATION
 When did you feel, how big is it initially? Symptoms?  4 Quadrants, Circular motion, Palpate less than 1 cm
Rate of the growth of the mass?  Mass: measurement, consistency, mobility, borders (well
 Cystic Benign, delineated or irregular)
 Hard & Fixed  Malignant  Supraclavicular & axillary (lymph node involvement)
AMENORRHEA 2. ABDOMINAL EXAMINATION

 E.g. LMP Apr 22 & 25 years old  DX: PREGNANCY 
st
1 : Inspection
 First things first: RULE OUT PREGNANCY 
nd
2 : Auscultation - bowel sounds, ascites (fluid wave,
shifting dullness common for patient with gynecologic
INFERTILITY malignancies)
rd
 3 : Palpation - if done first before auscultation, promote
3. MENSTRUAL HISTORY PERISTALTIC movement of the intestines.
 Relevance of Menstrual history? 
th
4 : Percussion - Tympanism
o Infertility, Amenorrhea, AUB
3. PELVIC EXAM
 Inspection  Palpation  Speculum Exam  Internal Exam (Bimanual)  Recto-Vaginal Exam
 Watch: http://www.youtube.com/watch?v=_ZThfli3UyI
Most important: PREPARATION

 Urinary bladder should be empty
o Full bladder: misdiagnosed as ovarian cyst
o Recto-sigmoid full of feces: should be empty
 ONLY case not allowed to void: URINARY INCONTINENCE
o Patient needs to strain (Valsalva), try to cough or laugh  Loss of urine (incontinence)
o If empty - cannot be able to demonstrate incontinence
LITHOTOMY
 Don’t examine the patient by yourself, properly draped, good light source esp. when the complaint is in the vulva
EXTERNAL:
 Inspection - mons pubis, distribution of pubic hair, pruritis (pubic lice), clitoris, labio majora & minora  urethral orifice,
vaginal opening, perineal opening, anus
 Palpation - Bulging at side of perineum or vulva, the most common structure: BARTHOLIN’S GLANDS as cyst or abscess
indicating infection.
 Discharge  STID (common: Gonococcal)  structures more affected: sub-urethral area (SKENE’s glands).
SPECULUM:
 Vagina + Cervix
 Lubricated (ideally), ungloved (speculum hand), gloved (non-speculum hand), lock  take specimen, unlock, slowly withdraw
 NO lubrication (tap water) in diagnostic examinations: PAP’s, grams stain, culture, (28:43)
 Grave’s speculum
o Cervix  Lateral walls
o Cervix: locate the External os: separate into anterior & posterior lip
 PAP smear
 Cancer screening test for problems on the cervix
 To recover cells that may have cancer (exfoliate)  atypical cells from lesion (malignancy)
o Specimen collection at ECTOCERVIX (Ayer’s) & ENDOCERVIX (Cytobrush) “CAN”
o Also from the POSTERIOR FORNIX - those that gravitate from the posterior wall (other end of Ayer’s)
o MOST IDEAL: CYTOBRUSH
o Specimen  Slide  Fixative (Hair Spray)
ANTERIOR LIP
CYTOBRUSH &
AYER’S SPATULA
GRAVE’S
SPECULUM POSTERIOR LIP
BIMANUAL EXAM
 Uterus + Adnexa
 May be an internal exam where you separate labia, insert 2 fingers, feel the cervix (hole in the middle depending upon the
gravidity: round (nulli), fish mouth (multi)  uterus  R lateral fornix (adnexa)  LLF (adnexa)
 For women who had sexual contact
 Other hand down: pelvic (to feel the uterus)
 Normal uterus - anteverted, firm, mobile, non-tender
 Lateral fornix: adnexa
RECTO-VAGINAL:
 Rectum + Back of Uterus
 For retroverted uterus, Endometriosis, Ovarian Tumors
 Middle finger - rectum, lesions at the back of the uterus
RECTAL EXAM:
 Uterus + Adnexa
 For virgin patients, > 50 yo prone to Colon Cancer
CASE 1
55 year old nulligravid, married for 20 years came for check-up. She is worried because her mother died of breast cancer and an
aunt has ovarian cancer, She has been menopausic at 52 years; never had post-menopausal bleeding.
FIRST:
 For menopausic patient, the most important thing to ask is for the presence of POST-MENOPAUSAL BLEEDING.
In our case, patient never had post-menopausal bleeding.
 Chief Complaint is concern for CANCER  so what are the PRESENTING SYMPTOMS? How do you feel now? Do you have any
particular problem? (Weight loss, easy fatigability)
Other details needed for risk in cancer:

 Personal Hx: Occupation (chemicals, radiation), cigarette, alcohol, illicit drug use
 PMH: past illnesses, hospitalizations, surgery
 Medication: HRT (treatment for women who had menopause showing menopausal symptoms), maintenance medication from
other co-morbidities (hypoglycemic, for HTN)
 Sexual History (prone to Hepatitis)
NOT CONCERN in Menstrual History

 MENARCHE: Patient will be too old to remember.
RISKS for Cancer: Family History & Nulligravid (HIGH RISK)
Ancillary Procedures:
1. Breast Cancer – Self Breast Examination, Mammography
2. Ovarian Cancer – UTZ, pelvic examination, PAP smear
3. Osteoporosis – Bone densitometry
4. Colon Cancer – Colonoscopy
Other basic: CBC, Liver Function Tests, Glucose, Lipid Profile
(Katz Book, Part 2; 7)

40 - 64 years old
 Annual Pap smear, mammography q1 - 2 years until age 50 then q1 yr, cholesterol q5 yrs, fasting glucose q3 yrs after age 45.
 High Risk: Hb, RUA, Fasting glucos, STD, HIV, TB skin test, Lipid profile, TSH, colonoscopy & Hepa C.
50 - Older
 Colonoscopy: FOBT q yr, FOBT + sigmoidoscopy q5 yrs, 2x contrast enema q5 yrs or colonoscopy q10 yrs, TSH q5 yrs beginning
at age 50.

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CASE 01: HISTORY & PHYSICAL EXAM

First Check-up: Complete physical examination

AMENORRHEA 2. ABDOMINAL EXAMINATION

Most important: PREPARATION

Other details needed for risk in cancer:

NOT CONCERN in Menstrual History

RISKS for Cancer: Family History & Nulligravid (HIGH RISK)

(Katz Book, Part 2; 7)

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