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GYNECOLOGICAL EXAM INATION

GYNECOLOGICAL EXAM INATION. Doç Dr Aslı Somunkıran İŞ. Anamnesis. Name and identity Gynecologic Anamnesis anamnez Obstetric Anamnesis Sexual fonx Medical history Family history Complaints. Identity. Age Marital status Duration of marriage Number of marriages Educational status-job.

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GYNECOLOGICAL EXAM INATION

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  1. GYNECOLOGICAL EXAMINATION Doç Dr Aslı Somunkıran İŞ

  2. Anamnesis • Name and identity • Gynecologic Anamnesis anamnez • Obstetric Anamnesis • Sexual fonx • Medical history • Family history • Complaints

  3. Identity • Age • Marital status • Duration of marriage • Number of marriages • Educational status-job

  4. Gynecologic Anamnesis • Age at Menarche (The first menstrual period); 13±2 • Menstrual cycle anamnesis • Cyclus length; 28±7 days • Duration of mns flow; 2-7 days • Amount of bld; 2-3 pads/day • LMP • Dysmenorrhea • PMS

  5. Polymenorrhea; cycles with intervals of 21 days or fewer (anovulatory cycles) Oligomenorrhea; menstrual periods occurring at intervals of greater than 35 days, with only four to nine periods in a year (anovulatory cycles-PCOS)

  6. Menorrhagia /hypermenorrhea; abnormally heavy and/or prolonged menstrual period at regular intervals • End polyps • Leiomyoma • End hyperplasia • Hypomenorrhea‎; • Asherman Syndrome • Genital tb

  7. Cryptomenorrhea • Imperforate hymen • Cervical stenosis

  8. Obstetric history • Gravida • Parity • Abortions; • Induced abortions • Miscarriages

  9. Sexual history • Dyspareunia • Postcoital bleeding • Contraception (metod; duration..)

  10. Medical history • Previous ops • Diseases • Medications • Hirsutism • galactorrhea • Dysuria • SUI, urgency

  11. Complaints Present complaints; • Duration • Location • Relation to other organic functions (mens flow, coitus, bowel movements....)

  12. Do a Complete Physical Assessment • HEENT • CV.. BLOOD PRESSURE • Lungs • Breasts • Abdomen • Pelvic/rectal • Neuro • Musculoskeletal

  13. Essentials for an Adequate Examination--Relaxation • Patient should be given an opportunity to empty her bladder prior to the exam-- Routine UA specimen may be obtained at this time • Explain what is to take place during the exam • Drape her appropriately, cover extending at least over her knees • Arms should be at her side or folded across her chest.

  14. Essentials for an Adequate Examination • Examiner's hands should be warmed, also warm the speculum before the exam • Have eye to eye contact with the patient during the exam • Explain in advance each step in the examination, avoiding any sudden or unexpected movements

  15. Essentials for an Adequate Examination • Male examiners should always be attended by female assistants • Hx should be taken prior to patient disrobing. • Do not enter the room with an unclothed patient unless you have a female chaperone.

  16. Correct Examining Position of the Patient • The Lithotomy Position/or Semi-Sitting Lithotomy Position • Lying in supine position • Thighs flexed and abducted • Feet resting in stirrups • Buttocks extended slightly beyond edge of exam table • Head supported with a pillow

  17. Correct Examining Position of the Patient

  18. Sequence of a Pelvic Examination • Inspect the patient's external genitalia • Perineal area must be well illuminated • Both hands are gloved to prevent the spread of infection • Perineum is sensitive and tender, warn the patient by touching the neighboring thigh first before advancing to the perineum.

  19. Note • A patient suffering pain or deformity of the joints may be unable to assume a Lithotomy position. • It may be necessary to have the patient abduct only one leg or have another person assist in separating the patient's thighs.

  20. Sequence of a Pelvic Examination • Mons pubis--note quantity and distribution of hair growth • Labia--usually plump and well-formed in adult female • Perineum--slightly darker than the skin of the rest of the body. Mucous membranes appear dark pink and moist

  21. Sequence of a Pelvic Examination • Separate the labia majora and inspect the labia minora; • Labia minora • Clitoris • Urethral orifice • Hymen • Vaginal orifice

  22. Sequence of a Pelvic Examination • Note the following: • Discharge • Inflammation • Edema • Ulceration • Lesions

  23. Sequence of a Pelvic Examination • Note abnormalities such as: • Bulges and swelling of vulva and vagina • Enlarged clitoris • Syphilitic chancres • Sebaceous cyst • Condylomas Primary Syphilis

  24. Sequence of a Pelvic Examination • Skene's glands • Near the urethra • Suspect inflammation; check for urethral discharge (Dc = Infxn Most likely GC) • Insert index finger with palm facing you into the vagina up to the 2d joint. Apply pressure upwards and milk the Skene's gland by moving your fingers outward • Do this on both sides and obtain specimen for culture in case of discharge. • Change glove if discharge is found.

  25. Sequence of a Pelvic Examination • If there is history or appearance of labial swelling check Bartholin's glands • Insert index finger up to first knuckle • With your index finger and thumb, palpate the posterolateral area of the labia majora noting any: • Swelling • Tenderness • Masses • Heat or discharge

  26. Sequence of a Pelvic Examination • Bartholin's glands (CONT) • A painful abscess is pus filled and usually staphylococcal or gonococcal in origin and should be incised and drained to perform C+S.

  27. Sequence of a Pelvic Examination • Assess the support of the vaginal outlet: • With the labia separated by middle and index finger • Ask patient to strain down • Note any bulging of the vaginal walls (cystocele and rectocele).

  28. Sequence of a Pelvic Examination • Inspect the anus at this time, note presence of lesions and hemorrhoids

  29. Speculum Examination of Internal Genitalia • Select a speculum of appropriate size, lubricate and warm with warm water (Commercially prepared lubricants interfere with pap smear studies) • Small--not sexually active female • Medium--sexually active • Large--women who have had children • Medium to large speculum may be used if female has had children.

  30. Speculum Examination of Internal Genitalia • Hold speculum in right hand • Place two fingers just inside or at the introitus and gently press down, this will help guide the speculum into the vagina opening • The speculum has to be closed • Insert closed speculum obliquely into vagina at a 45 degree angle rotating 50 degrees counterclockwise

  31. Speculum Examination of Internal Genitalia • Avoid trauma to the urethra • Care is taken to avoid pulling pubic hair or pinching the labia • Maintaining downward pressure, open blades slowly after full insertion and position the speculum so that the cervix can be visualized • When the cervix is in full view, the blades are locked in the open position

  32. Examination/Collection Specimen of the Cervix • Inspect the cervix • Color should be uniformly pink • Erythema around os: • Ectropion--expressed columnar epithelium • Erosion--term has been used to describe both the exposed columnar epithelium and the erythema seen with cervicitis • Pale--anemia • Bluish--Chadwick's sign, presumptive sign of pregnancy.

  33. Cervical inspection Lesions/cysts: • Nabothian cyst--endocervical retention cysts usually secondary to cervical infection/inflammation • Friable, granular, red or white patchy areas--be suspicious of dysplasia, needs to be evaluated with colposcopy • Ulcerative lesions--may be herpetic; do viral culture of lesions and refer for colposcopy • Polyps--soft, friable mass protruding through os; may bleed if traumatized; refer for evaluation/removal

  34. Cervical inspection Discharge: • Endocervical vs. from vaginal vault • Physiological discharge--odorless, colorless • Culture any discharge.

  35. Cervical inspection Cervical Os: • Nulliparous--small, round, oval • Parous/multiparous--linear, irregular, stellate

  36. Cervical inspection

  37. Examination/Collection Specimen of the Cervix • Obtain specimens • Chlamydia culture--most prevalent STD • GC culture--gram stain not reliable, done for screening, must do Thayer-Martin for confirmation

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