1. The gynaecological history taking
and physical examination
Dr YAY MON KYAW

2. History taking
• Patient identification-Name, age, parity,
occupation.
• A brief statement of the genernal nature and
duration of the main complaints.
• History of presenting complaints.
• Abnormal menstrual loss
• Pattern of bleeding – regular or irregular.
• Intermenstrual bleeding.
• Amount of blood loss- greater or less than usual

3. • 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 relieve the pain.
• Vaginal discharge- amount, colour, odour,
presence of blood.
• Abdominal mass

4. •Menstrual cycle
• Age of menarche.
• Usual duration of each period and length of cycle,
amount, dysmenorrhoea
• First day of last menstrual period.( L.M.P)
• Previous obstetric history
• Number of children with ages and birth weights.
• Any abnormalities with pregnancy, labour or the
puerperium.

5. Any termination of pregnancy with record of
gestation age and any complications
• Previous gynaecological history
Any previous gynaecological treatments or
surgery, date of last cervical smear.

6. •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 illness or operations with dates
• Family history

7. Enquiry about other systems
• Appetite, weight loss, weight gain.
• Bowels
• Micturation.
• Other systems.
Social history
• Socio-economical status
• Smoking, alcohol intake.
Drug history

8. Summary
• It is important to summarize the history in one
or two sentences before proceeding to
examination to alert the examiner to the
sailent features.

9. Examination
• Smiles, introduces her/himself
General examination
• Anaemia, jaudice
• Lymphnode
• Thyroid gland
• Extremities
Chest
Breasts – particularly relavant if there is a suspected
ovarian mass

10. Abdominal examination
• Empty the bladder before abdominal
examination
• She should be comfortable and lying semi-
recumbent, with a sheet covering her from
waist down, but the area from the
xiphisternum to the symphysis pubis should
be left exposed.
• It is usual to examine the women from her
right- hand side.

11. Inspection
• The contour of the abdomen should be
inspected- obvious disension or mass
• The presence of surgical scars, dilated veins or
striae gravidarum .
• It is important specially to examine the
umbilicus for laparoscopy scars and just above
the symphysis pubis for Pfannenstiel scars
(used for Caesarean section, hystrectomy,
etc….) , herniae or not

12. 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
the palpation.Palpation using the right hand is
performed, examining the left lower quadrant
and proceeding in a total of four steps to the
right lower quadrant of the abdomen.

13. • Examination for masses, liver, spleen and
kidneys.
• If the patient has pain, palpated gently and
look for signs of peritonism, i.e. guarding,
rigidity and rebound tenderness.
• Inguinal herniae and lymphnodes.

14. Percussion
• Percussion is particularly useful if free fluid is
suspected.In the recumbent position, ascitic
fluid will settled down into a horseshoes
shape and dullness in the flanks can be
demonstrated.
• As the patient moves over to her side, the
dullness will move to her lower most side, this
is known as shifting dullness.A fluid thrill can
also be elicited.

15. Ausculation
• Bowel sounds, bruit.
Pelvic examination
• Consent and female chaperone.Privacy.
• Needs gloves, speculum, lubricant.
• 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
vaginal wall with Sim’s speculum.

16. Positions
Dorsal position Lithotomy position

17. Sim’s position Left lateral position

18. Inspection
• Pubic hair distribution
• external genitalia- obvious lesion or
inflammation, discolouration , ulcer, mass ( 5’
or 7’ o clock- Bartholin’s cyst)
• Urethral orifice
• Perineum
• Abnormalities
• Discharge

19. Inspection of external genitalia

20. Bartholin’s cyst

21. Third degree utero-vaginal prolapse

22. Cusco’s speculum examination

23. Sim’s speculum examination

24. • Ask to strain down to enable the detection of
any prolapse and also to cough, as this will
show the sign of stress incontinence.
• A bivalve ( Cusco’s) speculum is inserted to
visualize the cervix.

26. • Vaginal wall
rugosities, mass, trauma, prolapse, vesicle
discharge
• Cervix
polyps, growth, ectopy
• Uterine prolapse

28. Ectopy cervix

29. Carcinoma cervix

30. Bimanual digital examination
• To use the fingers of right hand in the vagina
and to place left hand on the abdomen.
• In a virgin or a child , only a PR examination .
• Left hand is used to separate the labia minora
to expose the vestibule and the examing
fingers of the right hands are inserted.

31. Bimanual examination

32. Bimanual examination
• Cervix
size, position, mobility, consistency
( firm in non-pregnant & soft in pregnant
uterus)
tenderness ( in ectopic pregnancy )
• Uterus
position, AV/RV, mobility, size, mass related to
uterus, tenderness

33. • Both culs
Adnaxal mass ( ovarian cyst )
• POD
• Discharge on vaginal examination fingers

34. • The uterosacral ligaments can be palpated in
the posterior fornix- scarred or shortened in
endometriosis.
Rectal examination
• An alternative to VE in a virgin or a child
• It may be useful to differentiate between
enterocoele and rectocoele.