HOW TO EXAMINE FEMALE PATIENTS
In carrying out the examination, taking a history is the first step. It is said that 80% of the diagnosis is made on history alone. This gives a basis for subsequent physical examination and for initial decisions about diagnosis and treatment. The information gathered amid the physical examination helps the clinician in making decisions about the possible diagnosis to explain the patient’s symptoms.
GYNECOLOGIC HISTORY
Discussing reproductive issues may be difficult for some women, it is, therefore, important to obtain such history in a private and relaxed setting. If the patient is meeting the health care provider for the first time, she should be clothed. The patient is meant to be questioned alone but exceptions can be made for children, adolescent, or mentally impaired women or if the patient directly asks for such.
Questions asked during the interview should be asked in an open-minded and non-judgmental way as this may increase the level of comfort during the interview.
Aspects of the gynecologic history may include:
MENSTRUAL HISTORY
The goal of this section is to determine any problem associated with the menstrual period
The patient is asked:
- Age of menarche
- Last menstrual period
- Menstrual pattern such as her cycle length, duration of flow, amount of flow.
- Presence of menstrual associated symptoms such as breast tenderness, irritability, food cravings, weight gain, increased appetite, or abdominal swelling.
- The presence of bleeding after intercourse
- Associated pain at the time of menses
- Methods of contraception including complications associated with their use and the reason for the stoppage
In premenopausal or menopausal women, questions include:
- Bleeding pattern
- Associated symptoms associated with hormonal changes that occur around menopause such as hot flashes, sweats at night.
- Use of hormone therapy treatment or consumption of soy product in diet or through oral medication
- Consumption of herbal preparation
- The current method of contraception for premenopausal women that are sexually active
- Past methods of contraception including complications associated with their use and the reason for the stoppage
VAGINAL DISCHARGE
Questions should be asked about a change or increase in vaginal discharge. If present, she should be asked question about its color, smell, the presence of blood, the amount and whether there are any associated symptoms such as itching, burning, and malodor.
URINARY TRACT AND UTEROVAGINAL PROLAPSE SYMPTOMS
Uterine prolapse occurs when the muscle and ligaments of the pelvic floor stretch and weaken and loses its capability to provide support for the uterus. This results in the uterus slipping down or protruding into the vagina.
The patient may be asked about:
- Urinary leakage
- Sensation of heaviness or pulling in the pelvis
- If there is a feeling of something falling out of the vagina
- Frequent urination or frequent urge to urinate
- Frequent urinary tract infection
- Blood in the urine
- Urinary incontinence with activities that increase intra-abdominal pressure such as coughing or sneezing
SEXUAL SYMPTOMS
This may include an assessment of the type of sexual activity the patient is having and whether she has questions or concern about it.
If the patient is sexually active, it is important to ask whether she experiences dyspareunia (pain with sexual intercourse) and if the dyspareunia is superficial or deep. Causes of deep dyspareunia may include chronic pelvic inflammatory disease and endometriosis.
It is also important to inquire about past history of sexual assault or abuse. This may not be appropriate on the first visit.
CERVICAL CYTOLOGY
The most recent cervical smear (Pap smear) should be recorded with date and result.
It is essential to question the patient about any history of abnormal cervical smears, and if so, what was undertaken in the way of evaluation and treatment.
OBSTETRIC HISTORY
The patient would be asked:
- To list all pregnancies and outcomes including age at which each occurred
- About if the pregnancy ended in abortion or not. If yes, it is important to note if the abortion was induced or spontaneous.
- For pregnancies that last for more than 20 weeks, it is important to record gestational age at delivery, route of delivery, weight of the fetus at delivery, the presence of maternal or fetal complications and the current situation of the baby (if dead or alive)
- If there was a presence of group B streptococcal in previous pregnancies
PAST MEDICAL/SURGICAL HISTORY
Questions about past or present major illnesses would be asked, and if any hospitalization.
The patient would be asked to list all surgical procedures she has undergone either gynecologic or nongynecologic.
MEDICATION OR TREATMENT HISTORY
The patient may be asked to list all past and present medications, including over-the-counter medications, vitamins, herbal supplement and vitamins with their success and failures.
It is important to record allergic reactions to medications including the type of reaction experienced.
SOCIAL HISTORY
Aspect of the social history that may be important include past and present occupational history, level of education and marital relationship.
FAMILY HISTORY
Some gynecologic conditions are family related and so illnesses experienced by the family members should be listed including the members affected and the age of diagnosis of each. Illnesses such as cancer, diabetes mellitus, cardiovascular disease and some other hereditary disorders.