gynecological history and physical examination
DESCRIPTION
Gynecological history and Physical examination. OB/GYN Hospital, Fudan University, Shanghai, China Lu Yuan. Medical history collecting and writing Physical examination. Authenticity, systematicness and integrity of Medical history, largely depend on the interrogation methods and skills. - PowerPoint PPT PresentationTRANSCRIPT
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