Physical Examination A thorough gynecologic physical examination is typically performed at the time of the initial visit, on a yearly basis, and as needed throughout the course of treatment (Table 1.6). The extent of the physical examination during the gynecologic visit is often dictated by the patient’s primary concerns and symptoms. For example, for healthy teens without symptoms who are requesting oral contraceptives before the initiation of intercourse, a gynecologic examination is not necessarily required. Some aspects of the examination—such as assessment of vital signs and measurement of height, weight, blood pressure, and calculation of a body mass index— should be performed routinely during most office visits. Typically, examination of the breasts and abdomen and a complete examination of the pelvis are considered to be essential parts of the gynecologic examination. It is often helpful to ask the patient if the gynecologic examination was difficult for her in the past; this may be true for women with a history of sexual abuse. For women who are undergoing their first gynecologic examination, it may be useful to ask what they have heard about the gynecologic examination or to state: “Most women are nervous before their first exam, but afterward, most describe it as ‘uncomfortable.’”
Abdominal Examination With the patient in the supine position, an attempt should be made to have her relax as much as possible. Her head should be leaned back and supported gently by a pillow so that she does not tense her abdominal muscles. Flexion of the knees may facilitate relaxation.
The abdomen should be inspected for signs of an intra-abdominal mass, organomegaly, or distention that would, for example, suggest ascites or intestinal obstruction. Auscultation of bowel sounds, if deemed necessary to ascertain the nature of the bowel sounds, should precede palpation. The frequency of intestinal sounds and their quality should be noted. In a patient with intestinal obstruction, “rushes,” as well as the occasional high-pitched sound, can be heard. Bowel sounds associated with an ileus may occur less frequently but at the same pitch as normal bowel sounds.
The abdomen is palpated to evaluate the size and configuration of the liver, spleen, and other abdominal contents. Evidence of fullness or mass effect should be noted. This is particularly important in evaluating patients who may have a pelvic mass and in determining the extent of omental involvement, for example, with metastatic ovarian cancer. A fullness in the upper abdomen could be consistent with an “omental cake.” All four quadrants should be carefully palpated for any evidence of mass, firmness, irregularity, or distention. A systematic approach should be used (e.g., clockwise, starting in the right upper quadrant). Percussion should be used to measure the dimensions of the liver. The patient should be asked to inhale and exhale during palpation of the edge of the liver. Areas of tenderness should be evaluated after the examination of the rest of the abdomen.