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Obstetrics and Gynecological History and
Physical examination
Chao Gu M.D., Ph.D.
Dept of Ob/Gyn
OB/GYN Hospital, Fudan University
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Medical history collecting and writing (30 min)
Pelvic examination (15 min)
Test (30 min)
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Good communication is necessary for the assessment of patient's condition and treatment
communication technique
• concentration• Knowledge• Kindness• Humor?
Trust
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• General Item
• Chief Complaint
• Present Medical History
• Past Medical History
• Menstruation History
• Marriage History
• Social History
• Family History
Gynecologic History
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• General exam
• Abdominal exam
• Pelvic exam-- Gynecology examination
Gynecologic Physical Examination
Assistant Checkup
• Ordinary test
• Special test
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Physical Examination
• Symptoms
• General check up
• Abdomen examination
• Pelvic examination –Gynecology exam
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Name, Gender, age, nationality, marriage, occupation, hometown
Address, time of hospitalization, history collecting time, history provider
General Item
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The main symptoms or The duration of symptoms ( Professio
nal term, in 20 words)
•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
Chief Complaint
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• Chronology of chief complaint from when the patient first
felt well until the present
• Detailed description of the chief complaint
--occur, evolution, diagnosis and treatment
procedures
History of Present Illness
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Pain
•Location
•Timing (onset, duration and frequency)
•Quality (characteristics)
•Quantity or Severity
•Setting
•Alleviating or Precipitating factors
History of Present Illness
Bleeding
•Onset and Duration
•Constant or Intermittent
•Character
•Intensity
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Vaginal Discharge
•Duration
•Characteristics
•Associated Symptoms
•Temporally Related Events
History of Present Illness
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Past Medical History
• Medical illnesses (childhood and adult)
• Immunizations
• Surgical history
• Infectious diseases history
• Medications
• Allergies
• blood transfusion history
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• Age of menarche, menstrual cycle,volume, associated
symptoms, LMP/PMP, amenorrhea, menopausal age date
• LMP : Last menstrual period
• PMP : Previous menstrual period
The female patient, 27 years old, complaint in August menstruation was late, and previous menstrual date was on July 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
125
2850
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• 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
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Birth place, previous location
bad habits for cigarette and alcohol
Personal Information History
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Parents
cousins , sibling
children
Health conditions
Family History
• Any inheritable disorders
• Special attention to breast, ovarian and colon cancer
• Osteoporosis, heart disease and menopause
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Past obstetric history
• Outcome of previous pregnancies in details including the abortions
• Any significant antenatal, intrapartum or postpartum events
• Previous maternal complications
• Mode of delivery
• Baby weight
• Life & Health of the baby
Obstetric History
Abdominal exam
• Inspection
• Palpation
• Ascultation
• Percussion
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1 Please write a complaint according to the following information:
• Female patient, 42 years old, complaint in recent 1 years by the increased amount of menses, accompanying a backache with fatigue
• Female patient, 35 years old, lower abdominal pain for 2 days recent one month, and leucorrhea has peculiar smell
Discussion
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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
Discussion
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Medical history collecting and writing
Pelvic examination
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• Check carefully, gentle movement
• Urine evacuated before check ( urine preserved for checkup )
• Replace the one-time pad
• Bladder lithotomy position
Q: 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
Basic Requirements of the Pelvic Examination
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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
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Step 2
Check up by speculum
• Speculum forbidden without
agreement by virgin
• replacement and removal
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Step 3
Vaginal inspection
deformity: vaginal septum,
double vagina
new biological, ulcer, cyst or not
Vaginal discharge is normal, if
necessary, check leucorrhea
routine
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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
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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
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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.
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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
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1 Examination of vulva (5 points)
2 Speculum removal (5 points)
3 Speculum with lubricant (5points)
4Speculum two leaf close up (5 pints)
5Along 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 )Gynecological examination evaluation standard ( out of 100 points )
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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 )
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Gynecological examination evaluation standard ( out of 20 points )Gynecological examination evaluation standard ( out of 20 points )
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The end
Thank you !