KEY POINTS
381 We are all products of our environment, our background, and our culture. The
importance of ascertaining the patient’s general, social, and familial situation cannot
be overemphasized. The physician should avoid being judgmental, particularly with
respect to questions about sexual practices, gender identity, and sexual orientation.
2 Good communication is essential to patient assessment and treatment. The foundation
of communication is based on key skills: empathy, attentive listening, expert
knowledge, and rapport. These skills can be learned and refined.
3 The concepts of medical professionalism initially codified in the Hippocratic Oath
demand that physicians be circumspect with all patient-related information. For
physician–patient communication to be effective, the patient must feel that she is
able to discuss her problems in depth and in confidence.
4 Different styles of communication may affect the physician’s ability to perceive the
patient’s status and achieve the goal of optimal assessment and successful treatment.
The intimate and highly personal nature of many gynecologic conditions requires
particular sensitivity to evoke an honest response.
5 Some patients lack accurate information about their illnesses. Incomplete or
inadequate understanding of an illness can produce increased anxiety, dissatisfaction
with medical care, distress, coping difficulties, unsuccessful treatment, and poor
treatment response.
6 After a dialogue is established, the patient assessment proceeds with obtaining a
complete history and typically, performing a physical examination. Both of these
aspects of the assessment rely on good patient–physician interchange and attention
to details.
7 At the completion of the physical examination, the patient should be informed of the
findings. When the results of the examination are normal, the patient can be
reassured accordingly. When there is a possible abnormality, the patient should be
informed immediately; this discussion should take place after the examination, with
the patient clothed.
The practice of gynecology requires many skills. In addition to medical
knowledge, the gynecologist should develop interpersonal and communication
skills that promote patient– physician interaction and trust. The assessment must
be of the “whole patient,” rather than confined to her general medical status. It
should include any apparent medical conditions and the psychological, social, and
family aspects of her situation. To view the patient in the appropriate context,
environmental and cultural issues that affect the patient must be taken into
account. This approach is valuable in routine assessments, and in the evaluation
of specific medical conditions, providing opportunities for preventive care and
counseling on an ongoing basis.
39VARIABLES THAT AFFECT PATIENT STATUS
Many external variables exert an influence on the patient and on the care she
receives. Some of these factors include the patient’s “significant others”—her
family, friends, and personal and intimate relationships (Table 1-1). These
external variables include psychological, genetic, biologic, social, and
economic issues. Factors that affect a patient’s perception of disease and pain and
the means by which she has been taught to cope with illness include her
education, attitudes, understanding of human reproduction and sexuality, and
family history of disease (1–3). Cultural factors, socioeconomic status, religion,
ethnicity, language, age, gender identity, and sexual orientation are important
considerations in understanding the patient’s response to her care.
Table 1-1 Variables That Influence the Status of the Patient
Patient
Age
History of illness
Attitudes and perceptions
Sexual orientation
Habits (e.g., use of alcohol, tobacco, and other drugs)
Family
Patient’s status (e.g., married, separated, living with a partner, divorced)
Caregiving (e.g., young children, children with disabilities, aging parents)
Siblings (e.g., number, ages, closeness of relationship)
History (e.g., disease)
Environment
Social environment (e.g., community, social connectedness)
Economic status (e.g., poverty, insuredness)
Religion (e.g., religiosity, spirituality)
Culture and ethnic background (e.g., first language, community)
40Career (e.g., work environment, satisfaction, responsibilities, stress)
We are all products of our environment, our background, and our culture.
The importance of ascertaining the patient’s general, social, and familial
situation cannot be overemphasized (4,5). Cultural sensitivity may be
particularly important in providing reproductive health care (6).
[1] The context of the patient’s support system and family can and should be
ascertained directly. The family history should include a careful analysis of those
who had significant illnesses, such as cancer or an illness that the patient
perceives to be a potential explanation for her own symptoms. The patient’s
perspective of her illness can provide important information that guides the
physician’s judgment; specific questioning to elicit this perspective can improve
satisfaction with the interaction (4,7). The patient’s understanding of key events
in the family medical history and how they relate to her is important. The
patient’s sexual history, sexual orientation, relationships, and practices should be
understood, and her functional level of satisfaction in these areas should be
determined. The physician should avoid being judgmental, particularly with
respect to questions about sexual practices, gender identity, and sexual
orientation (see Chapter 17).
COMMUNICATION
[2] Good communication is essential to patient assessment and treatment.
The patient–physician relationship is based on communication conducted in an
open, honest, and careful manner that allows the patient’s situation and problems
to be accurately understood and effective solutions developed collaboratively.
Good communication requires patience, dedication, and practice and involves
careful listening and attention to verbal and nonverbal communication.
The foundation of communication is based on four key skills: empathy,
attentive listening, expert knowledge, and the ability to establish rapport.
These skills can be learned and refined (4,5,8). When the initial relationship
with the patient is established, the physician must vigilantly pursue interviewing
techniques that continue to create opportunities to foster an understanding of the
patient’s concerns. Trust is the fundamental element that encourages open
communication of the patient’s feelings, concerns, and thoughts, rather than
withholding information (9).
One very basic element of communication—sharing a common language and
culture—may be missing when a clinician interacts with a patient of limited or no
English proficiency. Language concordance between the physician and patient is
assumed in many discussions of communication. More than 21% of Americans
41speak a language other than English at home, and of these 41% reported to the
Census Bureau that they speak English less than very well (10). Language
barriers are associated with limited health literacy, compromised interpersonal
care, and lower patient satisfaction in health care encounters (11,12). While
language-concordant health care professionals are optimal, in-person medical
interpreters can mitigate these effects; video and telephonic interpretation provide
technologic solutions that help mitigate communication challenges with
individuals of limited English proficiency (13). The State of California recognized
the importance of communication in patient–physician interactions through a
provision in the Health and Safety Code that states “where language or
communication barriers exist between patients and the staff of any general acute
care hospital, arrangements shall be made for interpreters or bilingual professional
staff to ensure adequate and speedy communication between patients and staff”
(14). Training future physicians to work with interpreters is receiving increasing
attention in US medical schools and will contribute to improved clinical practice
and reduce health care disparities (15).
[3] Although there are many styles of interacting with patients, each physician
must determine and develop the best way that she or he can relate to patients.
Physicians must convey that they are able and willing to listen and that they
receive the information with utmost confidentiality (1,4). The concepts of
medical professionalism initially codified in the Hippocratic Oath demand
that physicians be circumspect with all patient-related information. The
Health Insurance Portability and Accountability Act (HIPAA), which took effect
in 2003, established national standards intended to protect the privacy of personal
health information. Initial fears expressed about the impact of HIPAA regulations
and the potential for legal liability led to discussions of appropriate
communication and physicians’ judgments based on the ethical principles of
confidentiality in providing good medical care (16,17) (see Chapter 2).
Communication Skills
It is essential for the physician to communicate with a patient in a manner
that allows her to continue to seek appropriate medical attention. The words
used, the patterns of speech, the manner in which words are delivered, even body
language and eye contact, are all important aspects of the patient–physician
interaction. The traditional role of the physician was paternalistic, with the
physician expected to deliver direct commands or “orders” and specific guidance
on all matters (5). Now patients appropriately demand and expect more balanced
communication with their physicians. Although they may not have equivalent
medical expertise, they do expect to be treated with appropriate deference,
respect, and a manner that acknowledges their personhood as equal to that of the
42physician. Doctor–patient communication is receiving more attention in medical
education and is being recognized as a major task of lifelong professional learning
and a key element of successful health care delivery (18).
Patients with rare or unusual conditions sometimes have more specific medical
knowledge of a given medical problem than the physician does. When this is the
case, the physician must avoid reacting defensively. A 2013 poll indicated that
one-third of Americans had researched symptoms or diagnoses online; 46% of
those individuals reported that their online research led them to seek medical care,
while 38% decided to manage their suspected health conditions without
consulting a clinician (19). The patient often lacks broader knowledge of the
context of the problem, awareness of the variable reliability of electronic sources
of information, the ability to assess a given study or journal report within a
historical context or in comparison with other studies on the topic, knowledge of
drug interactions, an ability to maintain objective intellectual distance from the
topic, or essential experience in the art and science of medicine. The physician
possesses these skills and extensive knowledge, whereas the patient has an
intensely focused personal interest in her specific medical condition. Surveys of
physicians’ perceptions of the impact of Internet-based health information on the
doctor–patient relationship found positive and negative perceptions; physicians
express concerns about a hindrance to efficient time management during an office
visit, but a positive perception of the potential effects on the quality of care and
patient outcomes (20). A collaborative relationship that allows patients
greater interactive involvement in the doctor–patient relationship can
potentially lead to better health outcomes (21–23).
Physician–Patient Interaction
The pattern of the physician’s speech can influence interactions with the
patient. Some important components of effective communication between
patients and physicians are presented in Table 1-2. There is evidence that
scientifically derived and empirically validated interview skills can be taught and
learned, and conscientious use of these skills can result in improved outcomes
(24). A list of such skills is found in Table 1-3.
[3] For physician–patient communication to be effective, the patient must feel
that she is able to discuss her problems in depth and in confidence. Time
constraints imposed by the pressures of office scheduling to meet economic
realities make this difficult; both the physician and the patient frequently need to
reevaluate their priorities. If the patient perceives that she participates in decision
making and that she is given as much information as possible, she will respond to
the mutually derived treatment plan with lower levels of anxiety and depression,
embracing it as a collaborative plan of action. She should be able to propose
43alternatives or modifications to the physician’s recommendations that reflect her
own beliefs and attitudes. There is ample evidence that patient communication,
understanding, and treatment outcomes are improved when discussions with
physicians are more dialogue than lecture. When patients feel they have some
room for negotiation, they tend to retain more information regarding health care
recommendations. The concept of collaborative planning between patients and
physicians is embraced as a more effective alliance than the previous model in
which physicians issued orders. The patient thus becomes more vested in the
process of determining health care choices. For example, decisions about the risks
and benefits of menopausal hormone therapy must be discussed in the context of
an individual’s health and family history, including her personal beliefs and goals.
The woman decides whether the potential benefits outweigh the potential risks,
and she is the one to determine whether or not to use such therapy. Whereas most
women prefer shared decision making in the face of uncertainty, with an
evidence-based discussion of her risks and benefits, others may want a more
directive approach (25). The physician’s challenge is to be able to personalize
the interaction and communication.
Table 1-2 Important Components of Communication Between the Patient and
Physician: The Physician’s Role
The Physician Is:
A good listener
Empathetic
Compassionate
Honest
Genuine
Respectful
Fair
Facilitative
The Physician Uses:
Understandable language
Appropriate body language
44A collaborative approach
Open dialogue
Appropriate emotional content
Humor and warmth
The Physician Is Not:
Confrontational
Combative
Argumentative
Condescending
Overbearing
Dogmatic
Judgmental
Paternalistic
Table 1-3 Behaviors Associated With the 14 Structural Elements of the Interviewa
Preparing the Environment
Create privacy
Eliminate noise and distractions
Provide comfortable seating at equal eye level
Provide access
Preparing Oneself
Eliminate distractions and interruptions
Focus
Self-hypnosis
Meditation
45Constructive imaging
Let intrusive thoughts pass through
Observation
Create a personal list of categories of observation
Practice in a variety of settings
Notice physical signs
Presentation
Affect
What is said and not said
Greeting
Create a personal stereotypical beginning
Introduce oneself
Check the patient’s name and how it is said
Create a positive social setting
Introduction
Explain one’s role and purpose
Check the patient’s expectation
Negotiate about differences in perspective
Be sure expectations are congruent with the patient’s
Detecting and Overcoming Barriers to Communication
Develop personal list of barriers to look for
Include appropriate language
Physical impediments such as deafness, delirium
Include cultural barriers
46Recognize the patient’s psychological barriers, such as shame, fear, and paranoia
Surveying Problems
Develop personal methods of initiation of problem listing
Ask “What else?” until problems are elicited
Negotiating a Priority Problem
Ask the patient for priorities
State own priorities
Establish mutual interests
Reach agreement on order of addressing issues
Developing a Narrative Thread
Develop personal ways of asking the patient to tell her story
Ask when last felt healthy
Ask about entire course of illness
Ask about recent episode or typical episode
Establishing the Life Context of the Patient
Use first opportunity to inquire about personal and social details
Flesh out developmental history
Learn about the patient’s support system
Learn about home, work, neighborhood, safety
Establishing a Safety Net
Memorize complete review of systems
Review issues as appropriate to specific problem
Presenting Findings and Options
Be succinct
47Ascertain the patient’s level of understanding, cognitive style
Ask the patient to review and state understanding
Summarize and check
Tape record and give the tape to the patient
Ask the patient’s perspectives
Negotiating Plans
Activate the patient
Agree on what is feasible
Respect the patient’s choices whenever possible
Closing
Ask the patient to review plans and arrangements
Clarify what to do in the interim
Schedule next encounter
Say goodbye
aLipkin M Jr. Physician–patient interaction in reproductive counseling. Obstet Gynecol
1996;88:31S–40S.
Derived from Lipkin M, Frankel RM, Beckman HB, et al. Performing the interview. In:
Lipkin M, Putnam SM, Lazare A, eds. The Medical Interview: Clinical Care, Education,
and Research. New York: Springer-Verlag; 1995:65–82.
There is evidence that when patients are heard and understood, they
become more vocal and inquisitive and their health improves. Participation
facilitates investment and empowerment. Good communication is essential to
the maintenance of a relationship between the patient and physician that will
foster ongoing care. Health maintenance, therefore, can be linked directly to the
influence of positive interactions between the physician and patient. Women who
are comfortable with their physician may be more likely to raise issues or
concerns and convey information about potential health risks and be more
receptive to the physician’s recommendations. This degree of rapport may
promote the effectiveness of health interventions, including behavior
modification. It helps ensure that patients return for regular care because they feel
48the physician is genuinely interested in their welfare and they have confidence in
the quality of treatment and guidance they receive.
When patients are ill, they feel vulnerable, physically and psychologically
exposed, and powerless. The physician, by virtue of his or her knowledge and
status, has power that can be intimidating. It is essential that the physician be
aware of this disparity and ensure that the “balance of power” does not shift too
far away from the patient. Shifting it back from the physician to the patient may
help improve outcomes (1,22). Physicians’ behaviors can suggest that they are not
respectful of the patient. Such actions as failing to maintain scheduled
appointment times, routinely holding substantive discussions when the patient is
undressed, or speaking to her from a standing position while she is lying down or
in the lithotomy position can emphasize the imbalance of power in the
relationship.
In assessing the effects of the patient–physician interaction on the outcome
of chronic illness, three characteristics associated with better health care
outcomes were identified (26):
1. An empathetic physician and a high level of patient involvement in the
interview.
2. Expression of emotion by the patient and physician.
3. Provision of information by the physician in response to the patient’s
inquiries.
Among patients with diabetes, these characteristics resulted in improved
diastolic blood pressure and reduction of HgA1c. The best responses were
achieved when an empathetic physician provided as much information and
clarification as possible, responded to the patients’ questions openly and honestly,
and expressed a full range of emotions, including humor. Responses improved
when the relationship was not dominated by the physician (26).
Studies of gender and language have shown that men tend to dominate
conversations, interrupt more frequently, and control the topics of the
conversation (27). As a result, male physicians may tend to take control, and this
imbalance of power may be magnified in the field of obstetrics and gynecology,
in which all the patients are women. Male physicians may be more assertive than
female physicians. Men’s speech tends to be characterized by interruptions,
command, and lectures, and women’s speech is characterized by silence,
questions, and proposals (27,28). Some patients may feel more reticent in the
presence of a male physician, whereas others may be more forthcoming with a
male than a female physician (29). Women’s preference for a male or female
physician may be based on gender as well as experience, age, competency,
49communication styles, and other skills (30–32). Although these generalizations
clearly do not apply to all physicians, they can raise awareness about the various
styles of communication and how they shape the physician–patient relationship
(28). These patterns indicate that [4] all physicians, regardless of their gender,
need to be attentive to their style of speech because it may affect their ability
to elicit open and candid responses from their patients (33,34). Women tend to
express their feelings in order to validate, share, and establish an understanding of
their concerns or establish a shared understanding of their concerns (27,35).
Different styles of communication may affect the physician’s ability to
perceive the patient’s status and to achieve the goal of optimal assessment and
successful treatment. The intimate and highly personal nature of many
gynecologic conditions requires particular sensitivity to evoke an honest patient
response.
Style
The art of communication and persuasion is based on mutual respect and fosters
the development of the patient’s understanding of the circumstances of her health.
Insight is best achieved when the patient is encouraged to question her physician
and not pressured to make decisions. Patients who feel “backed into a corner”
have the lowest compliance with recommended treatments (36).
Following are techniques to help achieve rapport with patients:
1. Use positive language (e.g., agreement, approval, and humor).
2. Build a partnership (e.g., acknowledgment of understanding, asking for
opinions, paraphrasing, and interpreting the patient’s words).
3. Ask rephrased questions.
4. Give complete responses to the patient’s questions.
The manner in which a physician guides a discussion with a patient will
determine the patient’s level of understanding and her ability to successfully
complete therapy. The term compliance has long been used in medicine; it
suggests that the patient will follow the physician’s recommendations or “orders.”
The term is criticized as being overly paternalistic; an alternative term, adherence
to therapy, is preferable (37,38). This term still implies that the physician will
dictate the therapy. A more collaborative approach is suggested by the phrase
successful use of therapy, which can be credited mutually to the physician and the
patient. With this phrase, the ultimate success of the therapy appropriately accrues
to the patient (39). If a directive is given to take a prescribed medication without a
discussion of the rationale for its use, patients may not comply, particularly if the
instructions are confusing or difficult to follow. Barriers to adherence may result
50from practical considerations: Nearly everyone finds a four times daily (qid)
regimen more difficult than daily use. A major factor in successful use is the
simplicity of the regimen (40,41). Practical factors that affect successful use
include financial considerations, insurance coverage, and literacy (42). A
discussion and comprehension of the rationale for therapy, along with the
potential benefits and risks, are necessary components of successful use; but they
may not be sufficient in the face of practical barriers. The specifics of when and
how to take medication, including what to do when medication is missed, have an
impact on successful use. Positive physician–patient communication is correlated
with patient adherence to medical advice (43).
[7] The presentation style of the information is key to its effectiveness. As
noted, the physician should establish a balance of power in the relationship,
including conducting serious discussions about diagnosis and management
strategies when the patient is fully clothed and face-to-face with the physician in a
private room. Body language is important during interactions with patients. The
physician should avoid an overly casual manner, which can communicate a lack
of respect or compassion. The patient should be viewed directly and spoken to
with eye contact so that the physician is not perceived as “looking off into the
distance.”
Laughter and Humor
Humor is an essential component that promotes open communication. It can
be either appropriate or inappropriate. Appropriate humor allows the patient to
diffuse anxiety and understand that (even in difficult situations) laughter can be
healthy (44,45). Inappropriate humor would horrify, disgust, offend, or generally
make a patient feel uncomfortable or insulted. Laughter can be used as an
appropriate means of relaxing the patient and making her feel better.
Laughter is a “metaphor for the full range of the positive emotions.” It is the
response of human beings to incongruities and one of the highest manifestations
of the cerebral process. It helps to facilitate the full range of positive emotions—
love, hope, faith, the will to live, festivity, purpose, and determination (44).
Laughter is a physiologic response, a release that helps us feel better and allows
us to accommodate the collision of logic and absurdity. Illness, or the prospect of
illness, heightens our awareness of the incongruity between our existence and our
ability to control the events that shape our lives and our outcomes. We use
laughter to combat stress, and stress reduction is an essential mechanism used to
cope with illness.
Table 1-4 Importance Attached to the Patient–Physician Relationshipa
51Strategies for Improving Communication
All physicians should appreciate the importance of the art of communication
during the medical interview. It is essential that interactions with patients are
professional, honorable, and honest. Issues that were reported to be important to
physicians regarding patient–physician interactions are presented in Table 1-4.
Similarly, patients suggested the importance of many of these same issues in
facilitating participatory decision making (46).
Following are some general guidelines that can help improve communication:
1. Listen more and talk less.
2. Encourage the pursuit of topics introduced by and important to patients.
3. Minimize controlling speech habits such as interrupting, issuing
commands, and lecturing.
4. Seek out questions and provide full and understandable answers.
5. Become aware of any discomfort that arises in an interview, recognize
when it originates in an attempt by the physician to take control, and
redirect that attempt.
6. Assure patients that they have the opportunity to discuss their problem
fully.
7. Recognize when patients may be seeking empathy and validation of their
feelings rather than a solution. Sometimes all that is necessary is to be
there as a compassionate human being.
In conducting interviews, it is important for the physician to understand
the patient’s concerns. Given the realities of today’s busy office schedules, an
52additional visit may be required to discuss some issues in sufficient depth. In
studies of interviewing techniques it was shown that although clinicians employ
many divergent styles, the successful ones tend to look for “windows of
opportunity” (i.e., careful, attentive listening with replies or questions at
opportune times). This communication skill is particularly effective for exploring
psychological and social issues during brief interviews. The chief skill essential to
allow the physician to perceive problems is the ability to listen attentively.
An interview that permits maximum transmission of information to the
physician is best achieved by the following approach (9):
1. Begin the interview with an open-ended question.
2. As the patient begins to speak, pay attention to her answers, her emotions,
and her general body language.
3. Extend a second question or comment, encouraging the patient to talk.
4. Allow the patient to respond without interrupting, perhaps by employing
silence, nods, or small facilitative comments, encouraging the patient to
talk while the physician is listening.
5. The physician should periodically summarize his or her understanding of
the history to confirm accuracy.
6. Expressions of empathy and understanding at the completion of the
interview along with a summary of the planned assessments and
recommendations will facilitate the closure of the interview.
Attentiveness, rapport, and collaboration characterize good medical
interviewing techniques. Open-ended questions (“How are you doing?” “How
are things at home?” “How does that make you feel?”) are generally desirable,
particularly when they are coupled with good listening skills (47).
Premature closure of an interview and an inability to get complete information
from the patient may occur for several reasons. They may result from failure to
recognize the patient’s particular concern, from not providing appropriate
opportunity for discussion, from the physician’s discomfort with sharing the
patient’s emotion, or perhaps from the physician’s lack of confidence that he or
she can deal with the patient’s concern. One of the principal factors undermining
the success of the interview is lack of time. This is a realistic concern perceived
by physicians, but skilled physicians can facilitate considerable interaction even
in a short time by encouraging open communication.
[5] Some patients lack accurate information about their illnesses. Incomplete
or inadequate understanding of an illness can produce dissatisfaction with
medical care and increased anxiety, distress, and coping difficulties, resulting
in unsuccessful treatment and poor treatment response. As patients
53increasingly request more information about their illnesses and more involvement
in decisions about their treatment, and as physicians attempt to provide more open
interactive discussions, there is an even greater need to provide clear and effective
communication. Although patients vary in their intellectual abilities, medical
sophistication, anxiety, denial, and the ability to communicate, the unfortunate
occurrence of impaired patient comprehension can be the product of poor
physician communication techniques, lack of consultation time, and in some
cases, the withholding of information considered detrimental to patient welfare.
If clinical findings or confirmatory testing strongly suggests a serious
condition (e.g., malignancy), the gravity and urgency of this situation must
be conveyed in a manner that does not unduly alarm or frighten the
individual. Honest answers should be provided to any specific questions the
patient may want to discuss (48).
Allowing time for questions is important, and scheduling a follow-up visit
to discuss treatment options after the patient has an opportunity to consider
the options and recommendations is often valuable. The patient should be
encouraged to bring a partner or family member with her to provide moral
support, serve as another listener to absorb and digest the discussion, and assist
with questions. The patient should be encouraged to write down any questions or
concerns she may have and bring them with her to a subsequent visit; important
issues may not come to mind easily during an office visit. If the patient desires a
second opinion, it should always be facilitated. Physicians should not feel
threatened by patient attempts to gain information and knowledge.
Valuable information can be provided by interviews with ancillary
support staff and by providing pamphlets and other materials produced for
patient education. Some studies demonstrated that the use of pamphlets is highly
effective in promoting an understanding of the condition and treatment options.
Others showed that the use of audiotapes, videotapes, or information on an
Internet site has a positive impact on knowledge and can decrease anxiety.
There are numerous medical Web sites that can be accessed, although the
accuracy of the information is variable and must be carefully reviewed by
physicians before recommending sites to patients. Physicians should be familiar
with Internet sources offering accurate information and be prepared to provide the
addresses of these sites if the patient expresses interest (49).
The relationship between the patient and her physician, as with all aspects of
social interaction, is subject to constant change. The state of our health is dynamic
and it affects our ability to communicate with others, including conversations
between patients and physicians. Open communication between patient and
physician can help achieve maximum effectiveness in the diagnosis,
treatment, and compliance for all patients.
54Talk to the heart, speak to the soul.
Look to the being and embrace the figure’s form.
Reach deeply, with hands outstretched.
Talk intently, to the seat of wisdom,
as life resembles grace.
Achieve peace within a fragile countenance.
Seek the comfort of the placid hour
Through joyous and free reflection
know the other side of the flesh’s frame.
JSB
HISTORY AND PHYSICAL EXAMINATION
[6] After a dialogue is established, the patient assessment proceeds with
obtaining a complete history and, if indicated, performing a physical
examination. Both of these aspects of the assessment rely on good patient–
physician interchange and attention to details. During the history and
physical examination, risk factors that may require special attention should
be identified. These factors should be reviewed with the patient when developing
a plan for her future care (see Chapter 21).
Depending on the setting—ambulatory office, inpatient hospitalization, or
outpatient surgical center—record keeping is typically facilitated by forms or
templates (increasingly, electronic templates as a component of the electronic
medical record [EMR]), which provide prompts for important elements of the
medical, family, and social history. One challenge is that paper forms and
electronic records do not always “mesh,” and these paper and electronic records
may be periodically unavailable. Efforts to develop patient-held medical records
are not yet widely adopted, although the increasing use of smart phones with
health applications (“apps”) facilitates patient record keeping of data such as
blood pressure readings, medication lists, and activity records. Menstrual-cycle
tracking is now part of the movement that has been termed the “quantified self”
(50,51).
History
After the chief complaint and characteristics of the present illness are ascertained,
the medical history of the patient should be updated. Increasingly, this
information is available electronically in the EMR, but should be confirmed with
the patient. The record should include her complete medical and surgical history,
her reproductive history (including menstrual and obstetric history), her current
55use of medications (including over-the-counter and complementary and
alternative medications), and a thorough family and social history.
A technique for obtaining information about the present illness is presented in
Table 1-5. The physician should consider which other members of the health
care team might be helpful in completing the evaluation and providing care.
Individuals who interact with the patient in the office—from the
receptionists to medical assistants, nurses, advance practice nurses (nurse
practitioners or nurse midwives)—can contribute to the patient’s care and
may provide additional information or insight or be appropriate clinicians
for providing follow-up. In some teaching hospitals, residents or medical
students may provide care and participate in an office setting. The role that
each of these individuals plays in a given office or health care setting may not
be apparent to the patient; care should be taken that each individual
introduces her- or himself at the opening of the interaction and explains his
or her role on the team. It may be necessary to discuss the roles and
functions of each individual member of the team. In some cases, referral to a
nutritionist, physical or occupational therapist, social worker, psychologist,
psychiatrist, or sex counselor would be helpful. Referral to or consultations with
these clinicians and with physicians in other specialty areas should be addressed
as needed. The nature of the relationship between the obstetrician-gynecologist
and the patient should be clarified. Some women have a primary clinician whom
they rely on for primary care. Other women, particularly healthy women of
reproductive age, consider their obstetrician-gynecologist their primary clinician.
The individual physician’s comfort with this role should be discussed and
clarified at the initial visit and revisited periodically as required in the course of
care. These issues are covered in Section III, Preventative Health Care and
Primary Care (see Chapters 21 and 22). Laboratory testing for routine care and
high-risk factors is presented in Chapter 21.
Physical Examination
A thorough gynecologic physical examination is typically performed at the
time of the initial visit, periodically, 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.
Gynecologists have traditionally recommended an annual pelvic examination to
screen for asymptomatic conditions, although the evidence for the utility of the
screening examination has been called into question (52,53). The American
56College of Obstetricians and Gynecologists continues to strongly recommend an
annual visit as an opportunity for a woman and her ob-gyn to discuss whether an
examination is appropriate for her (54). While strongly supporting shared
decision making around annual pelvic examinations for asymptomatic women,
those with symptoms suggestive of gynecologic disease, including menstrual
problems, vaginal discharge, incontinence, infertility, or pelvic pain, should have
a pelvic examination (54). 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.
Prior to performing the female pelvic examination, and while the patient is still
fully clothed, she should be questioned about previous experiences with the
examination. Is this her first gynecologic examination? Have previous
examinations been difficult or painful? Has she experienced past physical or
sexual abuse? While attention should always be given to performing a gentle and
atraumatic examination, for individuals with a past history of trauma, the
gynecologic examination can trigger flashbacks or can retraumatize. Women
should be informed that if the examination is too difficult for them, they can
request that it be discontinued. 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
encourage her to 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,” and 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.
Table 1-5 Technique of Taking the History of the Present Illness
571. The technique used in taking the history of the present illness varies with the
patient, the patient’s problem, and the physician. Allow the patient to talk about
her chief symptom. Although this symptom may or may not represent the real
problem (depending on subsequent evaluation), it is usually uppermost in the
patient’s mind and most often constitutes the basis for the visit to the physician.
During the phase of the interview, establish the temporal relation of the chief
symptom to the total duration of the illness. Questions such as, “Then up to the time
of this symptom, you felt perfectly well?” may elicit other symptoms that may
antedate the chief one by days, months, or years. In this manner, the patient may
recall the date of the first appearance of illness.
Encourage the patient to talk freely and spontaneously about her illness from the
established date of onset. Do not interrupt the patient’s account, except for minor
promptings such as, “When did it begin?” and “How did it begin?,” which will help
in developing the chronologic order in the patient’s story.
After the patient has furnished her spontaneous account (and before the next phase
of the interview), it is useful to employ questions such as, “What other problems
have you noticed since you became ill?” The response to this question may reveal
other symptoms not yet brought forth in the interview.
Thus, in the first phase of the interview, the physician obtains an account of the
symptoms as the patient experiences them, without any bias being introduced by the
examiner’s direct questions. Information about the importance of the symptoms to
the patient and the patient’s emotional reaction to her symptoms are also revealed.
2. Because all available data regarding the symptoms are usually not elicited by
the aforementioned techniques, the initial phase of the interview should be
followed by a series of direct and detailed questions concerning the symptoms
described by the patient. Place each symptom in its proper chronologic order and
then evaluate each in accordance with the directions for analyzing a symptom.
In asking direct questions about the details of a symptom, take care not to suggest
the nature of the answer. This particularly refers to questions that may be answered
“yes” or “no.” If a leading question should be submitted to the patient, the answer
must be assessed with great care. Subject the patient to repeated cross-examination
until you are completely satisfied that the answer is not given just to oblige you.
Finally, before dismissing the symptom under study, inquire about other
symptoms that might reasonably be expected under the clinical circumstances of the
case. Symptoms specifically sought but denied are known as negative symptoms.
These negative symptoms may confirm or rule out diagnostic possibilities suggested
by the positive symptoms.
3. The data secured by the techniques described in the first two phases of the
interview should now suggest several diagnostic possibilities. Test these
58possibilities further by inquiring about other symptoms or events that may form part
of the natural history of the suspected disease or group of diseases.
4. These techniques may still fail to reveal all symptoms of importance to the
present illness, especially if they are remote in time and seemingly unrelated to
the present problem. The review of systems may then be of considerable help in
bringing forth these data. A positive response from the patient on any item in any of
the systems should lead immediately to further detailed questioning.
5. Throughout that part of the interview concerning the present illness, consider
the following factors:
a. The probable cause of each symptom or illness, such as emotional stress,
infection, neoplasm. Do not disregard the patient’s statements of causative factors.
Consider each statement carefully, and use it as a basis for further investigation.
When the symptoms point to a specific infection, direct inquiry to water, milk, and
foods eaten; exposure to communicable diseases, animals, or pets; sources of
sexually transmitted disease; or residence or travel in the tropics or other regions
where infections are known to exist. In each of the above instances, ascertain, if
possible, the date of exposure, incubation period, and symptoms of invasion
(prodromal symptoms).
b. 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 with permission from Hochstein E, Rubin AL. Physical Diagnosis. New York:
McGraw-Hill; 1964:9–11.
The abdomen is palpated to evaluate the size and configuration of the
liver, spleen, and other abdominal contents. Percussion prior to palpation
59may suggest organomegaly. 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). If there is an area of particular tenderness, the examination typically
focuses on this area last. The patient should be asked to inhale and exhale during
palpation of the edge of the liver. With a history of acute pain, rebound tenderness
(suggesting peritoneal irritation) should be ascertained.
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. Labia minora
b. Clitoris
c. Urethral orifice
d. Vaginal outlet (introitus)
e. Hymen
f. Perineal body
g. Anus
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
60wall. 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. Discharge. This should be studied to detect trichomoniasis, monilia, and clue
cells and to obtain cultures, primarily for gonococci and chlamydia.
c. Mucosal characteristics (i.e., color, lesions, superficial vascularity, and
edema). The lesion may be:
i. Inflammatory—redness, swelling, exudates, ulcers, vesicles
ii. Neoplastic
iii. Vascular
iv. Pigmented—bluish discoloration of pregnancy (Chadwick sign)
61v. Miscellaneous (e.g., endometriosis, traumatic lesions, and cysts)
d. Structural abnormalities (congenital and acquired)
2. Inspect the cervix for the same factors listed above for the vagina. Note the
following comments relative to the inspection of the cervix:
a. Unusual bleeding from the cervical canal, except during menstruation, merits
an evaluation for cervical or uterine neoplasia.
b. Inflammatory lesions are characterized by a mucopurulent discharge from the
os and redness, swelling, and superficial ulcerations of the surface.
c. Polyps may arise either from the surface of the cervix projecting into the
vagina or from the cervical canal. Polyps may be inflammatory or neoplastic.
d. Carcinoma of the cervix may not dramatically change the appearance of the
cervix or may appear as lesions similar in appearance to an inflammation.
Therefore, a biopsy should be performed if there is suspicion of neoplasia.
D. Bimanual Palpation
The pelvic organs can be outlined by bimanual palpation; the examiner places one
hand on the lower abdominal wall and the finger(s) (one or two) (see Fig. 1-3) of
the other hand in the vagina (or vagina and rectum in the rectovaginal examination)
(see Fig. 1-4). Either the right or left hand may be used for vaginal palpation. The
number of fingers inserted into the vagina should be based on what can comfortably
be accommodated, the size and pliability of the vagina, and the weight of the
patient. For example, adolescent, slender, and older patients might be best examined
with a single-finger technique.
1. Introduce the well-lubricated index finger and, in some patients, both the index
and the middle finger into the vagina at its posterior aspect near the perineum.
Test the strength of the perineum by pressing downward on the perineum and
asking the patient to bear down. This procedure may disclose a previously
concealed cystocele or rectocele and descensus of the uterus.
Advance the fingers along the posterior wall until the cervix is encountered.
Note any abnormalities of structure or tenderness in the vagina or cervix.
2. Press the abdominal hand, which is resting on the infraumbilical area, very gently
downward, sweeping the pelvic structures toward the palpating vaginal fingers.
Coordinate the activity of the two hands to evaluate the body of the uterus for:
a. Position
b. Architecture, size, shape, symmetry, tumor
62c. Consistency
d. Tenderness
e. Mobility
Tumors, if found, are evaluated for location, architecture, consistency,
tenderness, mobility, and number.
3. Continue the bimanual palpation, and evaluate the cervix for position,
architecture, consistency, and tenderness, especially on mobility of the cervix.
Rebound tenderness should be noted at this time. The intravaginal fingers should
then explore the anterior, posterior, and lateral fornices.
4. Place the “vaginal” finger(s) in the right lateral fornix and the “abdominal” hand
on the right lower quadrant. Manipulate the abdominal hand gently downward
toward the vaginal fingers to outline the adnexa.
A normal tube is not palpable. A normal ovary (about 4 × 2 × 3 cm in size,
sensitive, firm, and freely movable) is often not palpable. If an adnexal mass is
found, evaluate its location relative to the uterus and cervix, architecture,
consistency, tenderness, and mobility.
5. Palpate the left adnexal region, repeating the technique described previously, but
place the vaginal fingers in the left fornix and the abdominal hand on the left
lower quadrant.
6. Follow the bimanual examination with a rectovaginal–abdominal examination.
Insert the index finger into the vagina and the middle finger into the rectum
very gently. Place the other hand on the infraumbilical region. The use of this
technique makes possible higher exploration of the pelvis because the cul-de-sac
does not limit the depth of the examining finger.
7. In patients who have an intact hymen, examine the pelvic organs by the rectal–
abdominal technique.
E. Rectal Examination
1. Inspect the perianal and anal area, the pilonidal (sacrococcygeal) region, and the
perineum for the following aspects:
a. Color of the region (Note that the perianal skin is more pigmented than the
surrounding skin of the buttocks and is frequently thrown into radiating folds.)
b. Lesions
i. The perianal and perineal regions are common sites for itching. Pruritus ani
63is usually indicated by thickening, excoriations, and eczema of the perianal
region and adjacent areas.
ii. The anal opening often is the site of fissures, fistulae, and external
hemorrhoids.
iii. The pilonidal area may present a dimple, a sinus, or an inflamed pilonidal
cyst.
2. Instruct the patient to “strain down” and note whether this technique brings into
view previously concealed internal hemorrhoids, polyps, or a prolapsed rectal
mucosa.
3. Palpate the pilonidal area, the ischiorectal fossa, the perineum, and the perianal
region before inserting the gloved finger into the anal canal.
Note the presence of any concealed induration or tenderness in any of these areas.
4. Palpate the anal canal and rectum with a well-lubricated, gloved index finger.
Lay the pulp of the index finger against the anal orifice and instruct the subject to
strain downward. Concomitant with the patient’s downward straining (which
tends to relax the external sphincter muscle), exert upward pressure until the
sphincter is felt to yield. Then, with a slight rotary movement, insinuate the finger
past the anal canal into the rectum. Examine the anal canal systematically before
exploring the rectum.
5. Evaluate the anal canal for:
a. Tonus of the external sphincter muscle and the anorectal ring at the anorectal
junction.
b. Tenderness (usually caused by a tight sphincter, anal fissure, or painful
hemorrhoids).
c. Tumor or irregularities, especially at the pectinate line.
d. Superior aspect: Reach as far as you can. Mild straining by the patient may
cause some lesions, which are out of reach of the finger, to descend
sufficiently low to be detected by palpation.
e. Test for occult blood: Examine the finger after it is withdrawn for evidence of
gross blood, pus, or other alterations in color or consistency. Smear the stool to
test for occult blood (guaiac).
6. Evaluate the rectum:
a. Anterior wall
64i. Cervix: size, shape, symmetry, consistency, and tenderness, especially on
manipulation
ii. Uterine or adnexal masses
iii. Rectouterine fossa for tenderness or implants
In patients with an intact hymen, the examination of the anterior wall of the
rectum is the usual method of examining the pelvic organs.
b. Right lateral wall, left lateral wall, posterior wall, superior aspect; test for
occult blood
Modified with permission from Hochstein E, Rubin AL. Physical Diagnosis. New York:
McGraw-Hill; 1964:342–353.
Pelvic Examination
The pelvic examination is usually performed with the patient in the dorsal
lithotomy position (Fig. 1-1). The patient’s feet should rest comfortably in
stirrups with the edge of the buttocks at the lower end of the table so that the
vulva can be readily inspected and the speculum can be inserted in the vagina
without obstruction from the table. Raising the head of the examination table, if
possible, may facilitate relaxation. Drapes should be placed to provide a measure
of cover for the patient’s legs but should be depressed over the abdomen to allow
observation of the patient’s expression and to facilitate communication.
65FIGURE 1-1 The lithotomy position for the pelvic examination.
Before each step of the examination, the patient should be informed of what
she will feel next: “First you’ll feel me touch your inner thighs; next I’ll touch the
area around the outside of your vagina.” The vulva and perineal area should be
carefully inspected. Evidence of any lesions, erythema, pigmentation, masses, or
irregularity should be noted. The skin quality should be noted and any signs of
trauma, such as excoriations or ecchymosis. Areas of erythema or tenderness are
noted, particularly in women with vulvar burning or pain, as might be seen with
vulvar vestibulitis or localized provoked vulvodynia. The presence of any visible
lesions should be quantitated and carefully described with regard to their full
appearance and characteristics on palpation (i.e., mobility, tenderness,
consistency). A drawing of the location of skin lesions is helpful. Ulcerative or
purulent lesions of the vulva should be evaluated and tested for infection as
outlined in subsequent chapters, and biopsy should be planned for any lesions if
the diagnosis is not apparent on inspection. It may be helpful to ask the patient if
she is aware of any vulvar lesions and to offer a mirror to demonstrate any
lesions.
66FIGURE 1-2 Vaginal specula: (1) Graves extra long; (2) Graves regular; (3) Pederson
extra long; (4) Pederson regular; (5) Huffman “virginal”; (6) pediatric regular; and (7)
pediatric narrow.
After thorough visualization and palpation of the external genitalia, including
the mons pubis and the perianal area, a speculum is inserted into the vagina. In a
healthy adult who is sexually active, a Pederson speculum is usually appropriate.
The types of specula that are used in gynecology are presented in Figure 1-2.
The smallest-width speculum necessary to produce adequate visualization
should be used. The larger Graves speculum may be required in women who
have lax vaginal walls, are pregnant, or will be undergoing cervical or
endometrial biopsies or procedures. In some women, a longer speculum (either
Pederson or Graves) may facilitate visualization of the cervix in a manner that is
less uncomfortable to the patient. If any speculum other than the typically sized
specula is used, the patient should be informed and documented in the medical
record. It can be helpful to encourage the patient to remind the clinician before
her next examination. The speculum should be warmed before it is inserted into
the vagina; a heating pad or speculum warmer should be placed under the supply
of specula. If lubrication is required, warm water generally is sufficient or a
small amount of lubricant can be used without interfering with cervical
cytology testing. The patient should be asked to relax the muscles of her distal
vagina before the insertion of the speculum to facilitate the placement and to
avoid startling her by this portion of the examination. After insertion, the cervix
and all aspects of the vagina should be carefully inspected. Particular attention
should be paid to the vaginal fornices, because lesions (e.g., warts) may be
present in those areas and may not be readily visualized.
67The appropriate technique and frequency for cervical cytology testing are
presented in Chapter 16. Biopsy should be performed on any obvious lesions
on the cervix or in the vagina. An endometrial biopsy usually is performed with
a flexible cannula (see Chapter 10). Any purulence in the vagina or cervix should
be cultured (see Chapter 15). Testing for sexually transmitted diseases should
be performed routinely in adolescents and young adults as recommended by
the Centers for Disease Control and Prevention.
After the speculum is removed, lubrication is applied to the examination glove,
and one or two (the index or index and middle) fingers are inserted gently
into the vagina to palpate the uterus and adnexal areas. In general, in righthanded physicians, the fingers from the right hand are inserted into the vagina and
the left hand is placed on the abdomen to provide counter pressure as the pelvic
viscera are moved (Fig. 1-3). In patients with pelvic pain, a stepwise “functional
pelvic examination” involves the sequential palpation of anatomic structures,
including the vaginal introitus, pelvic floor muscles, bladder, rectum, cervix, and
cul-de-sac. These areas are assessed for tenderness and a specific source of pain.
Pelvic floor muscle spasm is a common concomitant of pelvic pain. The vagina,
its fornices, and the cervix are palpated carefully for any masses or irregularities.
One or two fingers are placed gently into the posterior fornix so the uterus can be
moved. With the abdominal hand in place, the uterus usually can be palpated just
above the surface pubis. In this manner, the size, shape, mobility, contour,
consistency, and position of the uterus are determined. The patient is asked to
provide feedback about any areas of tenderness, and her facial expressions are
observed during the examination.
The adnexa are palpated gently on both sides, paying particular attention
to any enlargements. The size, shape, mobility, and consistency of any
adnexal structures should be carefully noted.
When indicated, a rectovaginal examination should be performed to
evaluate the rectovaginal septum, the posterior uterine surface, the adnexal
structures, the uterosacral ligaments, and the posterior cul-de-sac.
Uterosacral nodularity or posterior uterine tenderness associated with pelvic
endometriosis or cul-de-sac implants of ovarian cancer can be assessed in this
manner. Hemorrhoids, anal fissures, sphincter tone, rectal polyps, or rectal lesions
including carcinoma may be detected. A single stool sample for fecal occult blood
testing obtained in this manner is not adequate for the detection of colorectal
cancer and is not recommended (Fig. 1-4) (55).
68FIGURE 1-3 The bimanual examination.
69FIGURE 1-4 The rectovaginal examination.
At the completion of the physical examination, the patient should be
informed of the findings. When the results of the examination are normal,
the patient can be reassured accordingly. When there is a possible
abnormality, the patient should be informed immediately; this discussion
should take place after the examination with the patient clothed. A plan to
evaluate the findings should be outlined briefly and in clear, understandable
language. The implications and timing of any proposed procedure (e.g., biopsy)
should be discussed, and the patient should be informed when the results of any
tests will be available.
Pediatric Patients
70A careful examination is indicated when a child presents with genital
symptoms such as itching, discharge, burning with urination, or bleeding.
The examiner should be familiar with the normal appearance of the prepubertal
genitalia. The normal unestrogenized hymenal ring and vestibule can appear
mildly erythematous. The technique of examination is different from that used for
examining an adult and may need to be tailored to the individual child based on
her age, size, and comfort with the examiner.
A speculum examination should not be performed in a prepubertal child
in the office. A young child usually can be examined best in a “frog leg” or
“butterfly leg” position on the examining table. Some very young girls (toddlers
or infants) do best when held in their mother’s arms. Sometimes, the mother can
be positioned, clothed, on the examination table (feet in stirrups, head of table
elevated) with the child on her lap, the child’s legs straddling her mother’s legs.
The knee–chest position may be helpful for the examination (56). The child who
is relaxed and warned about touching will usually tolerate the examination
satisfactorily. An otoscope can be used to examine the distal vagina if indicated.
Two percent lidocaine jelly may be used as a topical anesthetic to facilitate the
examination if needed.
Some children who were abused, who had particularly traumatic previous
examinations, or who are unable to allow an examination may need to be
examined under anesthesia, although a gentle office examination should
almost always be attempted first. If the child had bleeding and no obvious cause
of bleeding is visible externally or within the distal vagina, an examination under
anesthesia is indicated to visualize the vagina and cervix completely. A
hysteroscope, cystoscope, or other endoscopic instruments can be used to provide
magnification and as a light source for vaginoscopy, which should be performed
under anesthesia.
Adolescent Patients
A pelvic examination may be less revealing in an adolescent than in an older
woman, particularly if it is the patient’s first examination or if it takes place on an
emergency basis. An adolescent who presents with excessive bleeding should
have a pelvic examination if she had intercourse, if the results of a pregnancy
test are positive, if she has abdominal pain, if she is markedly anemic, or if
she is bleeding heavily enough to compromise hemodynamic stability. The
pelvic examination occasionally may be deferred in young teenagers who have a
classic history of irregular cycles soon after menarche, who have normal
hematocrit levels, who deny sexual activity, and who will reliably return for
follow-up. A pelvic examination may be deferred in adolescents who present to
the office requesting oral contraceptives before the initiation of intercourse or at
71the patient’s request, even if she has had intercourse. Newer testing methods
using DNA amplification techniques allow noninvasive urine testing for
gonorrhea and chlamydia (57). Guidelines recommend that cervical cytology
testing in most adolescents be initiated at age 21 for virtually all young women,
with the exception of those who are HIV-infected or otherwise
immunocompromised (58).
Other diagnostic techniques (such as a transabdominal pelvic ultrasound) can
substitute for or supplement an inadequate examination. An examination usually
is required when there is a question of pelvic pain, genital anomaly, pregnancyrelated condition, or possibility of pelvic infection. The key to a successful
examination in an adolescent lies in earning the patient’s trust, explaining
the components of her examination, performing only the essential
components, and using a very careful and gentle technique. It is helpful to
ascertain whether the patient has had a previous pelvic examination, how she
perceived the experience, and what she heard about a pelvic examination from her
mother or friends.
Before a first pelvic examination is performed, a brief explanation of the
planned examination (which may or may not need to include a speculum),
instruction in relaxation techniques, and the use of lidocaine jelly at the
vaginal introitus/ hymenal ring can be helpful. An explanation should be
provided to the patient (and her mother, if the patient chooses), about the anatomy
of the hymen, noting that after menarche, the hymen is elastic and typically easily
distensible, and that a gynecologic examination does nothing to impact virginity
(59). The patient should be encouraged to participate in the examination by
voluntary relaxation of the introital muscles or by using a mirror if she wishes. If
significant trauma is suspected or the patient finds the examination too painful
and is truly unable to cooperate, an examination under anesthesia may be
necessary. The risks of general anesthesia must be weighed against the value of
information that would be obtained by the examination.
Confidentiality is an important issue in adolescent health care. A number of
medical organizations, including the American Medical Association, the
American Academy of Pediatrics, and the American College of Obstetrics and
Gynecologists, endorsed adolescents’ rights to confidential medical care.
Particularly with regard to issues as sensitive as sexual activity, it is critical that
the adolescent be interviewed alone, without a parent in the room. After
assurances of confidentiality (with the caveats dictated by state law relating to
mandatory reporting of suspected physical or sexual abuse), the patient should be
asked whether she engaged in sexual intercourse, whether she used any method of
contraception, used condoms to minimize the risks of sexually transmitted
diseases, or she feels there is any possibility of pregnancy.
72Follow-Up
Arrangements should be made for the ongoing care of patients, regardless of
their health status. Patients with no evidence of disease should be counseled
regarding health behaviors and the need for routine care. For those with signs and
symptoms of a medical disorder, further assessments and a treatment plan should
be discussed. The physician must determine whether she or he is equipped to treat
a particular problem or whether the patient should be directed to another health
professional, either in obstetrics and gynecology or another specialty, and how
that care should be coordinated. If the physician believes it is necessary to refer
the patient elsewhere for care, the patient should be reassured that this measure is
being undertaken in her best interests and that continuity of care will be ensured.
Patients deserve a summary of the findings of the visit, recommendations for
preventive care and screening, an opportunity to ask any additional questions, and
a recommendation for the frequency of any follow-up or ongoing care visits.
Ideally, the recommendations for care should be transmitted to the patient in
written form, as an “after visit summary” noting diagnoses, medications
prescribed, and recommendations for testing such as blood tests or imaging and
follow-up visits.
SUMMARY
The management of patients’ gynecologic symptoms, and abnormal findings and
signs detected during examination, requires the full use of a physician’s skills and
knowledge. Physicians are challenged to practice the art of medicine in a manner
that leads to effective alliances with their patients. The value of skilled medical
history taking cannot be overemphasized. Physicians should listen carefully to
what patients are saying about the nature and severity of their symptoms.
They should listen to what patients may not be expressing: their fears, anxieties,
and personal experiences that lead them to react in a certain manner when faced
with what is often, to them, a crisis (such as the diagnosis of an abnormality on
examination, laboratory testing, or pelvic imaging).
Physicians should supplement their formal education and clinical
experience by constantly seeking valid new information and honing their
communication skills. To meet the challenges posed by the complexities of
patient care, physicians must learn to practice evidence-based medicine, derived
from the very latest data of highest quality. Computers make the world of
information management accessible to both physicians and patients. Physicians
need to search the medical literature to acquire knowledge that can be applied,
using the art of medicine, to patient care that maintains health, prevents disease,
alleviates suffering, and manages and cures illness
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