Gynecological history and Physical examination

OB/GYN Hospital, Fudan University, Shanghai, China Lu Yuan

Medical history collecting and writing

Physical examination

Good communication is necessary for the assessment of patient's condition and treatment

communication technique consentration Knowledge kindness Humor?

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

Trustment

1.general item

2.Chief complaint

3.Present medical History

4.Past medical history

5.Menstruation history

6.Marriage history

7.Personal history

8.Family history

General Item

Name, Gender, age, nationality, marriage, occupation, hometown

Adress, time of hospitalization, history collecting time, history provider

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

Complaint

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

Present Medical History

Past Medical history

previous health conditiongeneral health condition and medical

historyOperation history of trauma, infectious

diseases history, vaccination history, allergic history, history of blood transfusion.

systematically review

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.

Menstruation 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

Marriage history

Personal information history

Birth place, previous location

bad habits for cigarette and alcohol

Family history

Parentscousins ， siblingchildren

Health conditions

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

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)

Gynecological examination evaluation standard ( out of 100 points )Gynecological examination evaluation standard ( out of 100 points )

The four step of obstetric palpationThe four step of obstetric palpation

Four step palpation evaluation standard ( out of 100 points )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 testspecial testspecial checkup

Date 、 serial number