The severity of the patient’s illness, as judged either by the presence of systemic symptoms, such as weakness, fatigue, loss of weight, or by a change in personal habits. The latter includes changes in sleep, eating, ﬂuid intake, bowel movements, social activities, exercise, or work. Note the dates the patient discontinued her work or took to bed. Is she continuously confined to bed?
c.
Determine the patient’s psychological reaction to her illness (anxiety, depression, irritability, fear) by observing how she relates her story as well as her nonverbal behavior. The response to a question such as, “Have you any particular theories about or fear of what may be the matter with you?” may yield important clues relative to the patient’s understanding and feeling about her illness. The reply may help in the management of the patient’s problem and allow the physician to give advice according to the patient’s understanding of her ailment.
Modified from Hochstein E, Rubin AL. Physical diagnosis. New York: McGraw-Hill, 1964:9–11, with permission.
Table 1.6 Method of the Female Pelvic Examination
The patient is instructed to empty her bladder. She is placed in the lithotomy position (Fig. 1.1) and draped properly. The examiner’s right or left hand, depending on his or her preference, is gloved. The pelvic area is illuminated well, and the examiner faces the patient. The following order of procedure is suggested for the pelvic examination:
A. External genitalia 1.
Inspect the mons pubis, labia majora, labia minora, perineal body, and anal region for characteristics of the skin, distribution of the hair, contour, and swelling. Palpate any abnormality.
2.
Separate the labia majora with the index and middle fingers of the gloved hand and inspect the epidermal and mucosal characteristics and anatomic configuration of the following structures in the order indicated below: a.
b.
c.
d.
e.
f.
g.
3.
If disease of the Skene glands is suspected, palpate the gland for abnormal excretions by milking the undersurface of the urethra through the anterior vaginal wall. Examine the expressed excretions by microscopy and cultures.
If there is a history of labial swelling, palpate for a diseased Bartholin gland with the thumb on the posterior part of the labia majora and the index finger in the vaginal orifice. In addition, sebaceous cysts, if present, can be felt in the labia minora.
B. Introitus
With the labia still separated by the middle and index fingers, instruct the patient to bear down. Note the presence of the anterior wall of the vagina when a cystocele is present or bulging of the posterior wall when a rectocele or enterocele is present. Bulging of both may accompany a complete prolapse of the uterus.
The supporting structure of the pelvic outlet is evaluated further when the bimanual pelvic examination is done.
C. Vagina and cervix
Inspection of the vagina and cervix using a speculum should always precede palpation.
The instrument should be warmed with tap water—not lubricated—if vaginal or cervical smears are to be obtained for the test or if cultures are to be performed.
Select the proper size of speculum (Fig. 1.2), warmed and lubricated (unless contraindicated). Introduce the instrument into the vaginal orifice with the blades oblique, closed, and pressed against the perineum. Carry the speculum along the posterior vaginal wall, and after it is fully inserted, rotate the blades into a horizontal position and open them. Maneuver the speculum until the cervix is exposed between the blades. Gently rotate the speculum around its long axis until all surfaces of the vagina and cervix are visualized.
1. Inspect the vagina for the following: a.
The presence of blood b.