Avi Harlev, Eyal Sheiner, and Arnon Wiznitzer

Achieving the right diagnosis and suggesting the proper treatment is a process that is greatly dependent upon the confidence the patient has in her caregiver. This process begins with an open, patient—physician dialogue, in which the patient feels comfortable relaying all relevant medical information to enable her physician to make the best medical decision.

Since intimate details are to be discussed, a private and quiet environment is required to allow the patient to relax and not only share enough details for her physician to understand her medical condition, but also voice her concerns and expectations. After a thorough medical history is taken, the next steps involve a physical examination as well as the appropriate imaging procedures and laboratory tests, depending on the setting (i.e., ambulatory care, outpatient, or in-patient hospitalization).

In addition to the history, this chapter focuses primarily on the gynecologic physical examination. Complete examination of the breast, abdomen, and pelvis are the core, vital elements of the gynecologic examination. The remainder of the examination depends upon the patient’s specific symptoms and complaints. For example, a thyroid gland examination should be performed for infertile women or women with menstrual disorders. Additionally, patients using hormonal therapy should be examined for any hypercoagulability event, such as deep vein thrombosis (DVT). Thus, the examining physician must be flexible about the questionnaires and specific tests that will be administered, and stay attuned to the patient’s specific verbal and other cues in order to guide this process.

Ascites: This is an accumulation of fluid in the peritoneal cavity. Although most commonly due to cirrhosis and severe liver disease, its presence can portend other significant medical problems. Diagnosis of the cause is usually with blood tests, an ultrasound scan of the abdomen and direct removal of the fluid by needle or paracentesis (which may also be therapeutic). Treatment may be with medication (diuretics), paracentesis, or other treatments directed at the cause.

Auscultation: This is a technical term for listening to the internal sounds of the body, usually using a stethoscope. Based on the Latin verb auscultare “to listen,” auscultation is performed for the purposes of examining the circulatory system and respiratory system (heart sounds and breath sounds), as well as the gastrointestinal system (bowel sounds).

Ectopic pregnancy: This is a complication of pregnancy, in which the fertilized ovum is implanted in any tissue other than the uterine wall. Most ectopic pregnancies occur in the fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen.

Endometriosis: This is a common health problem in women. The condition gets its name from the word endometrium, which is the tissue that lines the uterus (womb). In women with this problem, tissue that looks and acts like the lining of the uterus grows outside of the uterus, in other areas. These areas can be called growths, tumors, implants, lesions, or nodules.

Menstruation: This term refers to a woman’s monthly bleeding cycle, also called a period. Menstruation is part of the menstrual cycle, which prepares a woman’s body for pregnancy each month. A cycle is counted from the first day of one period to the first day of the next period. The average menstrual cycle is 28 days long. Cycles can range anywhere from 21 to 35 days in adults and from 21 to 45 days in young teenagers.

Müllerian duct anomaly: This is a congenital anatomical abnormality of the female internal genitalia due to nondevelopment or nonfusion of the muüllerian ducts or a failure of reabsorption of the uterine septus. Müllerian duct anomalies are common, occurring in 1–15% of women. However, clinically significant congenital uterine abnormalities are rare, with a reported incidence of between 0.1 and 0.5%.

Myoma: This is a kind of tumor, of which there are of two types: the leiomyoma may occur in the skin or gut, but the common form is the uterine fibroid; rhabdomyoma is a rare tumor of muscles, which occurs in childhood and often becomes malignant.

Palpation: This technique is used as part of a physical examination, in which an object is felt (usually with the hands of a health care practitioner) to determine its size, shape, firmness, or location. Palpation should not be confused with palpitation, which is an awareness of the beating of the heart.

Thrombophilia: This term describes the propensity to develop thrombosis (blood clots) due to an abnormality in the system of coagulation. Most women with a thrombophilia have healthy pregnancies. However, pregnant women with a thrombophilia may be more likely than other pregnant women to develop a venous thromboembolism or other pregnancy complications related to circulatory problems.

Chief Complaint

The chief complaint is a condensed summary of the reason the patient is seeking medical care. This information is typically condensed into a single sentence containing the following information:

• name
  
• age
  
• familial status
  
• residency
  
• the main medical issue that brings her to the physician

For example: Mrs. R. T., married +2, living in New York City, admitted due to postmenopausal bleeding for the last 2 days.

Present Illness

The present illness is typically recorded and described in significantly more detail. The physician should begin with open questions, allowing the patient to speak freely about her main complaint, asking only short questions such as “When did it start?”

In order to complete the history, the physician should follow up with more direct questions, including asking more details about every symptom mentioned by the patient. This part of the conversation will help the physician to strengthen the differential diagnosis of the patient.

Gynecologic History

In taking a gynecologic history, the physician should ask about the patient’s menstruation in great detail including:

• Age at menarche
  
• Regularity of her menstruation
  
• Date of her last menstrual period (LMP)
  
• Duration of her menstruation
  
• Length of her menstrual cycle (in days)

This information can be summarized in the formula: 5/28 (meaning 5 days of bleeding every 28 days).

Obstetric History