The gynaecological history and examination

Contents The Ten Teachers vi Acknowledgements vii Commonly used abbreviations viii 1. The gynaecological history and examination 1 2. Embryology and anatomy 6 3. Normal and abnormal sexual development and puberty 21 4. The normal menstrual cycle 32 5. Disorders of the menstrual cycle 43 6. Fertility control 59 7. Subfertility 76 8. Disordersof early pregnancy 89 9. Benign disease of the uterus and cervix 103 10. Endometriosis and adenomyosis 110 11. Benign tumours of the ovary 12. Malignant disease of the uterus and cervix 13. Carcinoma of the ovary and Fallopian tube 143 14. Conditions affecting the vulva and vagina 156 15. Infections in gynaecology 166 16. Urogynaecology 188 17. Uterovaginal prolapse 200 18. Menopause 207 19. Psychological aspects of gynaecology 218 Appendix 1: Common gynaecological procedures 232 Appendix 2: Medico-legal aspects of gynaecology 236 Index 239 C h a p t e r 1 The and History Examination gynaecological history examination Investigations O V E R V I E W A careful detailed history is essential before the examination of any patient In addition to a good general history, focusing on the history of the presenting complaint will allow you to customize the examination to elicit the appropriate signs and make an accurate diagnosis. When interviewing a patient to obtain her history, the consultation should ideally be held in a closed room with no one else present. Enough time should be allowed for the patient to express herself, and the doc-tor`s manner should be one of interest and under-standing. It is important that a template is used for history taking, as this prevents the omission of import-ant points. A sample template is given on page 2. Examination It is important that the examiner smiles, introduces her/himself by name and, if appropriate, asks the patient`s name. A handshake often helps to put the patient at ease. Important information about patients can be obtained by watching them walk into the examination room; poor mobility may affect decisions regarding surgery. While obtaining a history, it is possible to assess the patient`s affect. A history that is taken with sensitivity will often encourage the patient to reveal more details that are relevant to future management. Before proceeding to abdominal examination, a general examination should be performed. This includes examining the hands and mucous mem-branes for evidence of anaemia. The supraclavicular node should always be examined, particularly on the left side, where, in cases of abdominal malignancy, one might palpate the enlarged Virchow`s node (this is also known as Troissier`s sign). The thyroid gland should be palpated. The chest and breasts should always be examined; this is particularly relevant if there is a suspected ovarian mass, as there may be a breast rumour with secondaries 2 The gynaecological history and examination I Symptoms History-taking template Previous obstetric history The following outline is suggested. • Name, age, occupation • A brief statement of the general nature and duration ot the main complaints. History ol presenting complaint This section should focus on the presenting complaint, But certain important points should always be enquired about. • Abnormal menstrual loss. • Pattern of bleeding - regular or irregular. • Intermenstrual bleeding. • Amount of blood loss - greater ot less than usual • Number of sanitary towels or tampons used. • Passage of clots or flooding. • Pelvic pain - site of pain, nature and relation to periods. • Anything that aggravates or relieves the pain. • Number of children with ages and birth weights. • Any abnormalities with pregnancy, labour or the puerpenum. • Number of miscarriages and gestation at which they occurred. • Any termination of pregnancy with record of gestation age and any complications. Sexual and contraceptive history • History of discomfort, pain or bleeding during intercourse. • The use of contraception and type of contraception used. Previous medical history • Any serious illnesses or operations with dates. • Family history. Enquiry about other systems • Appetite, weight loss, weight gain • Bowels. • Vaginal discharge - amount, colour, odour, presence of blood. • Micturition. • Other systems. Obviously if the presenting complaint is one ot subfertility or is u re-gynaecological, the history mus! be appropriately tailored (see Chapters 7 and 16). Usual menstrual cycle • Age of menarche • Usual duration of each period and length of cycle. • First day ot the last period. Previous gynaecological history This section should include any previous gynaecological treatments or surgery. Trie date of the last cervical smear should also be recorded. in the ovaries known a"s Krukenburg tumours. In addition, a pleural effusion may be elicited as a conse-quence of abdominal ascites. The next step should be to proceed to abdominal and pelvic examination. Abdominal examination The patient should empty her bladder before the abdominal examination. She should be comfortable and lying semi-recumbent, with a sheet covering her from the waist down, but the area from the xiphisternum to the symphysis pubis should be left Social history The history regarding smoking and alcohol intake should be obtained. It is important to ascertain whether the woman is married or has a sexual partner Any family problems should be discussed, and it is especially important in the case of a frail patient to enquire about home arrangements if surgery is being considered. Summary It is important to summarize the history in one or two sentences before proceeding to examination to alert the examiner io the salient features exposed. It is usual to examine the woman from her right-hand side. Abdominal examination comprises inspection, palpation, percussion and, if appropriate, auscultation. Inspection The contour of the abdomen should be inspected and noted. There may be an obvious distension or mass (Fig. 1.1). The presence of surgical scars, dilated veins or striae gravidarum (stretch marks) should be noted. It is important specifically to examine the umbilicus for laparoscopy scars and just above the symphysis pubis Examination 3 to the examiner (many pelvic masses have disap-peared after catheterization). Figure 1.1 Abdominal distension. for Pfannenstiel scars (used for Caesarcan section, hysterectomy, etc.). The patient should be asked to raise her head or cough and any herniae or divarica-tion of the rectus muscles will be evident. Palpation First, if the patient has any abdominal pain, she should be asked to point to the site. This area should not be examined until the end of palpation. It is usual to get the patient to cough, as she may show signs of peritonism. Palpation using the right hand is per-formed, examining the left lower quadrant and pro-ceeding in a total of four steps to the right lower quadrant of the abdomen. Palpation should include examination for masses, liver, spleen and kidneys. If a mass is present but it is possible to palpate below it, it is more likely to be an abdominal mass rather than a pelvic mass. It is important to remember that one of the characteristics of a pelvic mass is that one cannot palpate below it. If the patient has pain, her abdomen should be pal-pated gently and the examiner should look for signs of peritonism, i.e. guarding and rebound tenderness. The patient should also be examined for inguinal her-niae and lymph nodes. Percussion Percussion is particularly useful if free fluid is sus- pected. In the recumbent position, ascitic fluid will settle down into a horseshoe shape and dullness in the flanks can be demonstrated. As the patient moves over to her side, the dullness will move to her lowermost side; this is known as `shifting dullness`. A fluid thrill can also be elicited. An enlarged bladder due to urinary retention will also be dull to percussion and this should be demonstrated Auscultation This method is not specifically useful for the gynaeco-logical examination. However, a patient will sometimes present with an acute abdomen with bowel obstruc-tion or a postoperative patient with ileus, and there-fore listening for bowel sounds may be appropriate. Pelvic examination Before proceeding to a vaginal examination, the patient`s verbal consent should be obtained and a female chaperone should be present tor any intimate examination. The external genitalia are first inspected under a good light with the patient in the dorsal position, the hips flexed and abducted and the knees flexed. The left lateral position is used for examination of prolapse or to inspect the vaginal wall with a Sims` speculum (Fig. 1.2). The patient is asked to strain down to enable the detection of any prolapse and also to cough, as this will show the sign of stress incontinence. After this, a bivalve (Cusco`s) speculum is inserted to visualize the cervix (Fig. 1.3). It is usual to warm the speculum to make the examination more comfortable for the patient. If taking a smear test, this is performed at the same time. Bimanual digital examination is then performed (Fig. 1.4). This technique requires practice. It is cus-tomary to use the fingers of the right hand in the vagina and to place the left hand on the abdomen. In a virgin or a child, only a rectal examination should be performed. The left hand is used to separate the labia minora to expose the vestibule and the examin-ing fingers of the right hand are inserted. The cervix is palpated and any hardness or irregularity noted. The hand on the abdomen is placed just below the umbil-icus and the fingers of both hands are then used to pal-pate the uterus. The size, shape, position, mobility and tenderness of the uterus are noted. The tips of the vaginal fingers are then placed into each lateral fomix and the adnexae are examined on each side. Except in a very thin woman, the ovaries and Fallopian tubes are not palpable. The uterosacral ligaments can be pal-pated in the posterior fornix and may be scarred or shortened in women with endometriosis. 4 The gynaecological history and examination `.`... . Figure 1.2 (a) Sims` speculum. (b) Sims` speculum exposing anterior vaginal wall. Figure 1.3 (a) Cusco`s speculum. (b)Cusco`s speculum in position with the blades opened exposing the cervix. (a) (b) Figure 1.4 (a] Bimanual examination of the pelvis, assessing uterine size, (a) Examining the lateral fornix. ... - tailieumienphi.vn