Features of collecting anamnesis in gynecological patients. The main symptoms of gynecological diseases

It is a collection of data that includes a wide range of factors that correlate with the state of the reproductive and reproductive systems female body. Particular attention is required to be paid to the nature of sexual, menstrual, reproductive and secretory functions, as well as past diseases and various surgical interventions.

Conducting a survey

During the interview of the patient, it is necessary to organize it in accordance with the following scheme:

• Passport data of the patient.
• existing complaints.
• Pathologies transferred in the past.
• Functioning of the reproductive system.
• The functioning of the urinary system and intestines.
• Presence of pain sensations and their nature.
• The history of the formation of this pathology.

After completing the collection of information for compiling a gynecological history, the doctor assesses the general condition of the patient - it is measured arterial pressure and the pulse rate is determined, then an examination of the whole body is organized, the lungs and heart are listened, etc. Then the doctor proceeds to a two-handed examination and, according to indications, other diagnostic methods are used.

It is important!

In the event of an urgent need surgical intervention in acute conditions, a specialist is often deprived of the opportunity to conduct an additional study, and also cannot observe a complete picture of the disease in dynamics. Much attention is paid to the age of the patient.

The role of the menstrual cycle in history

The main and primary link in the collection of a gynecological history is an assessment of the function of menstruation, which subsequently plays an important role in diagnosing the disease.

When assessing menstrual function, the following points become the main consideration:

1. The beginning of the first menstruation and its features.
2. The duration of the cycle of menstruation, and from when the regular cycle was established.
3. The duration and nature of bleeding during menstruation, features and volume of blood loss.
4. Changes in the menstrual cycle after the onset of sexual activity, childbirth and abortion.
5. Date of last normal menstrual period.

The time of the onset of menstruation indicates the degree of development of the reproductive system in a girl - whether this process is normal or with deviations. For example, the appearance of the first menstruation after the age of 16 and the accompanying pain indicate the infantilism of the reproductive system. This is also indicated by the time it took to establish menstruation - more than six months. At the same time it is necessary to take into account hereditary factors.

The course of the menstrual cycle and menstruation enable the specialist to conclude that the patient may have diseases. As an example of a gynecological history, if a patient has heavy and prolonged bleeding, then this may indicate the development of inflammation of the uterus or a malfunction of the ovaries, an abnormal position of the uterus and other pathologies that correlate with stagnation of blood in the small pelvis. As for non-gynecological problems, the doctor may suspect infectious pathologies, blood flow disorders, or hypovitaminosis.

It is important!

The appearance of bleeding between periods can indicate signs of tumor development, polyps in the uterus or ovaries, or the result of a hormonal imbalance in the female body.

The absence of menstruation in a woman of reproductive age increases the doctor's suspicions about the presence of polycystic ovaries, neuroendocrine abnormalities and intoxications in the body.

Sometimes pain during menstruation is considered a consequence of infantilism of the reproductive system, improper position of the uterus or inflammation of the genital organs. A burdened gynecological history requires a more thorough examination of the patient.

In connection with the listed deviations, we can conclude that it is very important when visiting a doctor to tell him as much information as possible about the menstruation cycle. An integrated approach to the treatment of pathology helps to diagnose possible deviations at the early stages of their development and make the treatment process as effective as possible.

The main components of the anamnesis

Special gynecological history is a broad concept and is not only information about the menstrual cycle. At the same time, the doctor must establish the characteristics of a woman’s sexual life, namely, the usefulness of sexual desire, because its decrease or complete absence in reproductive age may indicate anatomical failures in the structure of the organs of the reproductive system and some complex gynecological diseases.

It is important!

The specialist should clarify with the woman whether there are any violations during the sexual intercourse, whether it causes pain. The gynecologist also pays attention to the issues of contraception used by the patient. For example, intrauterine contraceptives can cause pain during menstruation, heavy bleeding, etc.

Information about previously transferred gynecological and venereal pathologies, obtained in the process of collecting data from the anamnesis, helps the doctor to find out the main cause of complaints. A complicated gynecological history also occurs when diseases that were not treated in the past appear after a certain time.

If the doctor has information about the patient's problems in the past, then it will not be difficult for him to identify this and develop an appropriate treatment in a short time. In this case, the patient must strictly adhere to all recommendations and periodically visit a specialist for a follow-up examination.

Of great importance for the diagnosis is a correctly conducted survey of the patient in order to clarify her complaints, collect information about the previous life and previous diseases (anamnesis of life), as well as information about the development of this disease (anamnesis of the disease). The survey is carried out according to a specific plan.

Passport data. Of particular importance is the age of the patient in connection with the anatomical and functional features of the genital organs. The same phenomenon in different periods of a woman's life can be both the norm and a symptom of a disease. For example, the absence of menstruation (amenorrhea) in childhood and old age is the norm, and in the childbearing period it indicates either pregnancy or a pathological condition. Abundant leucorrhoea at a young age often indicates the presence of an inflammatory process, and in the elderly - about a malignant neoplasm.

Complaints. Complaints with which the patient goes to the doctor are subjective symptoms of the disease. Most often, gynecological patients complain of pain, leucorrhea, bleeding and other disorders of menstrual function, infertility, disruption of neighboring organs. Patients may also present complaints characteristic of diseases of other organs and systems. Pain is the most frequent complaint with gynecological diseases. common cause pains are mechanical irritations (stretching, contraction, displacement) of tissues.

Painful sensations are accompanied by spastic contractions of the uterus (during abortion, submucosal uterine myoma), contractions of the fallopian tubes (during tubal pregnancy). Pain occurs when the nerve endings or plexuses are compressed by tumors, with infiltrates of inflammatory or tumor origin.

Scars and adhesions lead to tissue displacement and pain. When talking with the patient, it is not enough to reveal only the fact of the presence of pain. It is necessary to clarify their nature, intensity, localization and irradiation.

By nature, pains are distinguished as cramping, aching, stabbing, cutting, shooting, pulling. Cramping pains are characteristic of diseases accompanied by contractions of the muscles of the genital organs (abortion, tubal abortion, submucosal uterine fibroids). Aching pains are characteristic of inflammatory processes, and with an increase in the intensity of inflammation, a rupture of the pyosalpinx, they can become cutting, even “dagger-like”.

It is necessary to find out the intensity of pain, their duration. Pain is especially intense when a tube or ovary abscess ruptures, as well as when a cancerous tumor of the genital organs metastasizes.

Paroxysmal pain is characteristic of the termination of tubal pregnancy. Constant pain is typical for inflammatory processes and malignant tumors.

For the diagnosis of the disease, localization of pain is important. Most often, in gynecological diseases, pain is localized in the lower abdomen, in the left or right iliac region, sacrum, and in diseases of the external genital organs - at the site of the lesion. With the spread of the inflammatory process, pains capture larger areas, and sometimes become spilled throughout the abdomen.

Gynecological diseases are characterized by irradiation of pain in the sacrum, thigh, subclavian region (phrenicus symptom).

Other complaints (pain, bleeding, infertility, disruption of neighboring organs) will be discussed below, since detailed information about them can be obtained by questioning about the relevant functions: secretory, menstrual, sexual, reproductive, etc. Heredity. This section of the anamnesis of life gives an idea of ​​family diseases, that is, of a hereditary predisposition to certain diseases. It turns out that the next of kin have mental, endocrine diseases, alcoholism, malignant neoplasms, diseases of the blood and metabolism. With a hereditary predisposition and corresponding adverse conditions disease may occur. However, it is necessary to explain to the patient that burdened heredity does not predetermine the indispensable occurrence of the disease.

Living conditions. Living conditions from an early age affect the development of the whole organism. Of particular importance is the nature of nutrition, which should be sufficient and complete, especially during puberty. Insufficient, excessive or malnutrition can lead to improper formation of the reproductive system, as well as to disruption of menstrual and reproductive functions.

It is necessary to find out the living conditions of the woman, how her housework and rest are organized. overly large physical exercise at home can lead to the occurrence of a number of diseases or to the deterioration of their course. Heavy lifting shortly after childbirth, hard work in old age can cause omission or prolapse of the genitals.

Working conditions, the profession of the patient, the presence of occupational hazards (dustiness, chemical hazards, vibration, radiation, etc.) can have an adverse effect on the course of some diseases. Prolonged forced position during work can cause back pain.

Familiarization with working and living conditions gives a more complete picture of the causes of the disease.

Transferred general diseases. It's important to find out chronological order past diseases, paying attention to the features of their course, treatment and outcome. This is especially important in diseases with a chronic course, prone to relapse.

Chronic tonsillitis, mumps, measles transferred during puberty can have an adverse effect on the formation of menstrual function, cause underdevelopment of the female genital organs (infantilism) Diseases such as malaria, tuberculosis, rheumatism, frequent tonsillitis and pneumonia, especially those suffered in childhood, also can lead to a delay in sexual and general physical development, which in the future may manifest as a violation of menstrual function, infertility, miscarriage.

It is important to establish whether the patient has undergone surgery in the past, especially on the organs abdominal cavity. So, the transferred appendectomy can lead to inflammation of the uterine appendages, adhesive process, ectopic pregnancy.

The presence of concomitant diseases is also found out. Comorbid medical or psychiatric illnesses may aggravate or alter clinical picture gynecological disease, complicate its diagnosis and treatment.

A special place is occupied by an indication in the anamnesis of transferred blood transfusions. It should be clarified whether a blood transfusion was performed and for what reason, whether there was a pathological reaction to blood transfusion.

It also turns out an allergic history, i.e. the presence of allergic reactions to any food or medicinal substances. This is important for prescribing drug therapy, which should be tailored to drug tolerance.

menstrual function. Menstrual function characterizes the state of the reproductive system and the whole body of a woman. Menstrual dysfunction may indicate both gynecological and extragenital diseases. The nature of the menstrual function during its formation, during puberty, in the pre- and postmenopausal periods is being clarified.

The timely development of the menstrual function is evidenced by the age at which the first menstruation appeared (menarche). Usually, the first menstruation appears at the age of 13-14 and becomes regular after 5-6 months.

It should be found out whether menstruation during the period of their formation was accompanied by pain, fever, fainting, nausea, vomiting, etc., what were menstruation (scanty or heavy). Late appearance, prolonged development of menstrual function, meager, painful menstruation indicate underdevelopment of the genital organs.

Menstrual function is characterized by the duration, regularity, painfulness of menstruation and the amount of blood lost during this. Usually, menstruation lasts from 3 to 7 days, the duration of the menstrual cycle (from the 1st day of one menstruation to the 1st day of the subsequent menstruation) is 21-35 days (28-day menstrual cycles are most common). Normally, menstruation can be accompanied by mild pain in the lower abdomen and in the sacrum, which do not reduce the woman's performance. The intensity of menstruation is specified by the number of daily pads changed (normally 3-4 per day). It is necessary to find out if the type of menstruation has changed throughout life (with the onset of sexual activity, after childbirth, abortion, various diseases), and if it has changed, then it is important to know how, when and in connection with what.

It should be clarified whether menstruation is accompanied by poor health, whether there is engorgement and soreness of the mammary glands, discharge from the nipples.

In case of violation of menstrual function, its nature is clarified. So, for example, with submucosal uterine fibroids, polyposis, cancer, endometriosis, spotting between menstruation is possible. Violation of menstruation in connection with the onset of sexual activity, childbirth, abortion may indicate inflammation of the genital organs. Abundant and painful menstruation can be with fibroids, endometriosis, inflammation of the uterine appendages, etc.

The duration of menstrual bleeding should not exceed the usual. Random spotting, scanty or abundant, can be a symptom of endometrial pathology, including cancer.

If the patient has already entered menopause, it is necessary to find out how the transition period proceeded, what was the nature of menstruation at that time, whether there was bleeding, whether diagnostic curettage was performed, etc. It should be clarified at what age menopause occurred (usually menstruation stops at 49 --50 years), does not happen spotting from the vagina. The presence of such secretions after the onset of menopause is a characteristic symptom of endometrial cancer.

The survey is completed by clarifying the nature of menstruation during the present illness and the date of the last normal menstruation.

secretory function. The patient may complain of profuse vaginal discharge - leucorrhoea. At normal condition of the reproductive system, a woman always has slight discharge from the genital tract, but they are almost invisible, do not have an unpleasant odor and do not irritate the surrounding tissues.

In pathological processes, leucorrhoea can acquire an unusual color, bad smell, appear burning, itching in the vulva.

Whites have a different origin. On the eve of the vagina, they are formed from the secret of the sebaceous and sweat glands of the vulva, the secret of the large glands of the vestibule, paraurethral passages. The appearance of leucorrhoea may be associated with inflammation of the vulva or irritation of the vulva with a pathological secret from the vagina, uterus.

Vaginal leucorrhoea is usually a small amount of whitish liquid, consisting of transudate and desquamated cells of stratified squamous epithelium, and is milky white in color. Pathological vaginal leucorrhoea occurs in connection with inflammation of the walls of the vagina (colpitis), usually of infectious origin, as well as with vaginal cancer.

Cervical leucorrhoea is normally secreted by the mucous glands of the cervical canal. Usually they accumulate in the cervix and in the middle of the menstrual cycle are released in the form of a transparent, colorless, viscous mucus. The constant secretion of mucous whites from the cervical canal is usually the result of ruptures of the cervix during childbirth, after which there is an eversion of the mucous membrane of the canal. Increased leucorrhoea is possible with chronic inflammation of the cervix, cervical erosion, polyps, cancer.

Uterine leucorrhea is normally absent. They can occur in inflammatory processes of the uterine mucosa, uterine cancer, uterine myoma. The uterine leucorrhoea is watery, sometimes with an admixture of blood, the color of meat slops. The fallopian tubes are rarely a source of leucorrhoea. The secret can accumulate in the tubes when they become inflamed and are periodically released through the uterine cavity to the outside. These secretions may be serous or purulent. Amber-colored, watery leucorrhoea can be with cancer of the fallopian tubes.

When questioning the patient, one should find out from her the fact of the presence of leucorrhoea, their nature (color, smell, consistency, quantity), the frequency of appearance, the connection with the periods of the menstrual cycle and establish their cause.

sexual function. When questioning a patient in order to determine the nature of sexual function, a special tact should be shown. Finding out the presence of disorders of sexual function allows you to clarify the nature of the gynecological disease.

It should be found out at what age a woman has been sexually active, whether she is married (first or second), what is its duration. It is important to establish whether the onset of sexual activity was accompanied by inflammatory diseases (leucorrhea, cramps during urination). It is necessary to know what method of contraception the patient is protected from pregnancy (type and duration of contraceptive use).

The absence of pregnancy for more than 2 years with regular sexual activity without the use of contraception gives reason to consider the marriage as fruitless.

reproductive function. It is necessary to find out how many pregnancies the patient had, how they proceeded and how they ended. It is important to know how long after the onset of sexual activity the first pregnancy occurred. If pregnancy does not occur within 2 years from the onset of sexual activity, they speak of primary infertility. If, after one or several pregnancies within 2 years, pregnancy does not occur again, they speak of secondary infertility, which is more often observed after an abortion, and may also be the result of an inflammatory process of the female genital organs after complicated childbirth. It is equally important to find out the course of childbirth, the presence of surgical interventions, the body weight of the child at birth, the presence of ruptures of the cervix and perineum, the course of the postpartum period, and the duration of lactation.

If the pregnancy ended in an abortion, you should find out whether it was spontaneous or artificial, at what gestational age it occurred, how the period after the abortion proceeded, whether there was an increase in body temperature, bleeding, whether repeated curettage was performed, etc. The patient may also complain about miscarriage pregnancy.

Rarely occurring pregnancies, their spontaneous termination, premature birth may indicate hormonal deficiency. An unfavorable course of childbirth, complications after childbirth and abortion can lead to inflammatory processes, ectopic pregnancy, and infertility. The consequence of bleeding during childbirth may be a violation of menstrual function (Shee-hyun's syndrome).

Functions of neighboring organs. The female genital organs are anatomically closely related to the urethra, bladder, ureters, blind, sigmoid and rectum, appendix. They have a common source of innervation and blood supply. Therefore, in gynecological diseases, pathological processes in neighboring organs can be observed and vice versa. In gynecological diseases (fibroids), urination disorders and bowel function may occur. In this regard, complaints about dysfunction of neighboring organs should be clarified. To determine the state of the urinary system, it is necessary to know the frequency of urination, whether it is painful.

Urination can be accelerated with incorrect positions of the uterus and vaginal walls, with uterine myoma, especially when the tumor is located in the neck or isthmus of the uterine body.

Urinary incontinence may indicate urogenital fistulas. Partial urinary incontinence occurs with severe prolapse of the uterus and vaginal wall. Urination can be difficult up to acute urinary retention with complete prolapse of the uterus due to the bending of the urethra or when it is compressed by a tumor located in the neck or isthmus of the uterine body. Sometimes urinary incontinence and difficulty urinating can be combined: urine is excreted in small portions and complete emptying of the bladder does not occur. This can be observed with incorrect positions of the uterus.

In some gynecological diseases (inflammatory processes, especially acute and spreading to the pelvic peritoneum, gonorrhea of ​​the lower parts of the reproductive system, when cystitis and urethritis may develop at the same time), pain may occur during urination.

The cause of painful urination may be the spread of the malignant process of the uterus to the urinary organs. In this case, compression of the ureter by a malignant infiltrate and difficulty or complete cessation of urine outflow are possible, which manifests itself sharp pains in the lumbar region.

Gynecological diseases are often accompanied by disorders of bowel function. To determine its condition, it is necessary to know the nature of the stool (constipation, diarrhea, tenesmus, stool color, blood or mucus in it). When squeezing the lower intestines with tumors of the female genital organs, there may be complaints of constipation, and when the tumor grows into the intestinal lumen, the appearance of blood in the feces. Constipation is also possible with posterior bending of the uterus, pronounced prolapse rear wall vagina and pelvic floor muscle failure.

Diarrhea can occur in the acute stage of inflammation of the uterine appendages, especially when the process spreads to the peritoneum.

Incontinence of gases and feces is observed in rectoperitoneal and rectovaginal fistulas due to rupture of the perineum III degree (during childbirth).

Disorders of the functions of the intestines and bladder may also indicate independent diseases of these organs. To clarify this, there are methods of additional research. Gynecological diseases. When collecting anamnesis, it is necessary to find out previous gynecological diseases, since the present disease can be an exacerbation of a previously existing pathological process. With indications of a gynecological disease suffered in the past, it is necessary to ask the patient how it proceeded, what treatment was carried out and what was its result.

History of gynecological disease. When collecting an anamnesis of this disease, it is important to clarify the time of its onset, the cause of the occurrence. Hypothermia, menstruation, a recent abortion or childbirth can contribute to the development of an acute inflammatory process or an exacerbation of a chronic one; sudden movements, lifting weights can lead to torsion of the pedicle of the ovarian cyst, to rupture of the cyst.

It is necessary to find out how the disease developed, what diagnostic and treatment methods were used, what was the result.

Properly collected anamnesis gives an idea of ​​the disease and allows you to make a presumptive diagnosis. The final diagnosis can be established only after an objective examination of the patient and analysis of the results.

For the recognition of gynecological diseases, data on menstrual, reproductive, secretory, and sexual functions are of great importance.

Menstrual disorders often occur when the function of the nerve centers that regulate the activity of the endocrine glands, which are involved in preparing for pregnancy and its term, is impaired. The functional instability of this system can be congenital or acquired as a result of damaging factors (diseases, stressful situations, malnutrition) in childhood and during puberty.

Gynecological diseases can be both the cause of reproductive dysfunctions (infertility, spontaneous abortions, anomalies of labor forces), and their consequence (inflammatory diseases that have arisen after abortion and childbirth, neuroendocrine disorders after heavy bleeding in parturient women and puerperas, the consequences of obstetric injuries).

Pathological secretion (leucorrhoea) can be a manifestation of the disease of different parts of the genital organs.

There are whites:

Tubal (emptying hydrosalpinx)

Uterine (or corporal) (endometritis, polyps, early endometrial cancer)

Cervical leucorrhea (endocervicitis, eroded ectropion, erosion, polyps)

Vaginal.

At healthy women there is no visible discharge from the genital tract. The processes of formation and resorption of the vaginal contents of the vaginal mucosa are completely balanced. Vaginal leucorrhoea appears when pathogenic microorganisms are introduced (violation of the hygiene of sexual intercourse, gaping of the genital gap after perineal ruptures, etc.), unreasonable douching of the vagina, and the use of irrational contraceptives.

Great attention deserves data on sexual function. Disorders of sexual function are observed in many gynecological diseases. Sexual desire, sexual feeling and satisfaction characterize the maturity of women's sexual function. The absence of these indicators of sexual function is observed in gonadal dysgenesis and other endocrine disorders, as well as in many gynecological diseases.

Pain during sexual intercourse is typical for:

endometriosis (retrocervical)

inflammatory diseases

• colpitis

  salpingoophoritis

genital hypoplasia

vaginismus

It is necessary to know about violations of the function of adjacent organs: the state of the urinary tract and intestines (the presence of urethritis, cystitis, intestinal hypotension, flatulence, and others). These disorders also occur in many gynecological diseases.

II. Methods of gynecological examination.

Disease history :

• Family status

Gynecological history :

Age at which menstruation started (menarche)

Regularity of the menstrual cycle

duration of menstruation

The duration of the menstrual cycle from the first day of the last menstruation to the first day of the next menstruation

Example: menstruation began at the age of 13, lasts for 5 days, the duration of the menstrual cycle is 28 days.

Number of births, with age and weight of children at birth

Any pathology during pregnancy, childbirth or in the postpartum period

Number of miscarriages, indicating the gestational age, date of miscarriage, presence of complications

Any termination of pregnancy with an indication of the term, method of termination.

sexual intercourse;

any discomfort or pain in cases of infertility;

whether sexual intercourse is normal;

the frequency and timing of sexual intercourse during the menstrual cycle.

Contraception.

use of an intrauterine device

the use of oral contraceptives is particularly important because of their possible effect on menstruation.

Anamnesis of life.

• Details of any serious illnesses or operations are given.

  Family history is important.

History of present illness.

abnormal menstrual bleeding is noted;

cycle of bleeding;

the amount of blood lost (more or less than usual);

the number of used sanitary towels or tampons;

discharge of blood clots or non-clotting blood;

the presence of pain with blood loss;

pelvic pain: place, nature and relationship with menstruation.

Emotional problems.

clarifies the relationship with a husband or sexual partner;

problems in the family are identified;

psycho-emotional overload at home and at work.

Examination of the patient.

You can get a lot of information about the general condition of the patient by observing her when taking an anamnesis. The patient should be monitored on a case-by-case basis. For example, it is necessary to note how a woman looks: sick or healthy, high or low nutrition. It should be indicated whether the patient is willing to answer questions or reluctantly, trying to hide something or talking about symptoms that she thinks may lead to a diagnosis that she fears. Whether she is depressed, agitated, or suffering from some kind of emotional disorder, the symptoms of which are an unconscious expression of a need for help.

Examination of the abdominal wall.

The patient should lie flat, and if the abdomen is swollen and there is tension in the muscles of the anterior abdominal wall, then the patient should bend her knees in order to reduce muscle tension. The bladder must be empty.

Inspection.

The size and shape of the abdomen is noted. An increase in the abdomen in the midline may indicate the presence of a tumor of the uterus or ovaries. An increase in the size of the abdomen along the periphery is possible with ascites. Attention is drawn to the condition of the skin, the presence of a white line of the abdomen, rashes, pigmentation or scars (scars).

Palpation.

The abdomen should always be examined with a warm hand, and preferably with the flat of the hand rather than with the fingertips, as deep palpation can then be made painlessly for the patient.

Tumors arising from the small pelvis, if they are not impacted or fixed with adhesions, can easily move from side to side (but not up and down), and in this case it is impossible to palpate the lower edge of the tumor. Tumors can be solid or cystic (i.e. solid or fluid-filled). If liquid tumors are large enough, then they are well palpated with a flat palm and are well palpated. Ascites gives liquid trembling, which is determined by the presence of dullness on percussion.

Percussion

Percussion allows you to decide whether the swelling is in contact with the abdominal wall and this is the cause of the dull sound, or if these are bowel loops located between the tumor and the abdominal wall. If during percussion of the abdomen a ringing sound is determined in the center and dull on the sides, and this dull sound moves with a change in the position of the patient, then the presence of free fluid can be diagnosed.

Auscultation

When listening with a stethoscope, intestinal peristalsis is usually heard. A "silent" abdomen indicates intestinal paralysis and is found in cases of shock, generalized peritonitis, and postoperative paralytic ileus.

Gynecological examination :

Examination of the external and internal genital organs gives a lot of information about the patient. The presence of hypoplasia of the small and large lips, pallor and dryness of the vaginal mucosa are clinical manifestations of hypoestrogenism. "Juiciness" of the mucous membrane, cyanotic color of the mucous membrane of the vulva, abundant transparent secretion are signs of an increased level of estrogen.

Looking in mirrors.

Visual examination of the vagina is performed using mirrors. The examination should be carried out carefully without causing pain to the patient. This requires a small amount of sterile lubricant. It should be taken directly from the tube so that it does not become contaminated and cause cross-infection. The lubricating substance should be transparent, so that it would be possible to differentiate the secretions on it, and should not contain antiseptics that interfere with bacteriological examination.

There are 2 types of mirrors: Cusco double-leaf mirror and Sims spoon-shaped mirror.

Sims Mirror designed to detect vesico-vaginal fistulas. It consists of two concave blades of various sizes connected by a handle.

Double Mirror Cusco consists of two blades fixed together. This makes it possible to perfectly examine the cervix and vaginal mucosa. The doctor's hands are free.

Passport section.

1. FULL NAME.

Kasatkina Elena Sergeevna

2. Age

3. Gender

4. Profession

Krasnodar College of Electronic Instrumentation - student.

5. Home address

Krasnodar Western district, st. Stankostroitelnaya d.24 kv.111.

6. Time of admission to the clinic

7. Sending institution

NMF puberty

8. Diagnosis at admission.

NMF according to the type of opsomenorrhea.

9. The diagnosis is clinical.

Violation of menstrual function, puberty according to the type of algoopsomenorrhea. Genital infantilism. Hypofunction of the ovaries.

II . Subjective examination data

Patient's complaints:

For irregular and painful menstruation. Pain is localized in the lower abdomen during the first 2 days.

Disease history:

He considers himself ill since December 1998, when 10 days before the expected menstruation, violent discharge of blood began, about which she turned to a gynecologist. Treatment: gentamicin, Ca gluconate, vitamins, FTL. On 12/31/98, menstruation began on time. In February and March, menstruation was normal, only they were painful in the first 2 days, 6 days each, in March from 10 - 16.03. On March 28, blood discharge appeared again, also accompanied by pain, periodically the discharge was dark brown, periodically scarlet, and continued until April 16. - CaCl 2 electrophoresis. Since May 5, 1999, she has been taking motherwort, cynarizine, tincture of Eleutherococcus. I measured the basal temperature 37.2 - 37.1. 5.05 began menstruation (ended 11.05). It usually went away, just as painfully in the first 2 days.

Anamnesis of life:

Heredity is not burdened.

Was born on time. Fed naturally. She grew and developed in accordance with sex and age. She started walking at 11 months. In psychomotor development, she did not lag behind her peers.

From childhood infections, she suffered from chickenpox, mumps, rubella, and often had acute respiratory infections.

Hemotransfusion denies. There were no allergic reactions.

Operations were not performed.

Mensis from the age of 11, not immediately established, irregular, duration 6-7 days, after 20-40 days, painful in the first 2-3 days from the first menstruation, moderate. The day before menstruation headache. Last menstruation 05/05/99 - ended 05/11/99.

In 1993, for opsomenorrhea, homeopathic treatment was carried out, after which the cycle was 40 days long (within a year).

Sex life is denied. Secretory function is expressed moderately.

Contraceptives were not used.

There were no pregnancies.

tuberculosis, STDs, viral hepatitis, denies mental illness in himself and his relatives.

Has no bad habits.

Working and living conditions are good.

III. Data from an objective study.

General inspection.

The patient's condition is satisfactory . The position is active. Consciousness is clear. Body temperature 36.7 o C. Correct physique, reduced nutrition. Height 159 cm, weight 45 kg. The mammary glands are soft, painless, there are single dark hairs around the nipples. The skin is of physiological color, clean, turgor is normal. There were no hemorrhages on the skin and mucous membranes. The subcutaneous fat is poorly developed, the muscles are moderately developed. There are no edema. Lymph nodes are not palpable. The thyroid gland is not visualized. The joints are painless during active and passive movements, their configuration is not changed.

Respiratory system.

Breathing through the nose is not difficult. The type of breathing is mixed. NPV 16 per minute. The form chest normosthenic, no deformities, painless on palpation. Percussion - a clear pulmonary sound. Vesicular breathing is auscultated, no wheezing.

Inferior borders of the lungs:

The cardiovascular system.

There are no protrusions and pulsations of the carotid arteries. Palpation apex beat is located in the V intercostal space 1.5 cm medially from the mid-clavicular line. The cardiac impulse is not determined. The boundaries of relative and absolute cardiac dullness were not changed.

The diameter of the heart is 11 cm. The configuration of the heart is not changed.

auscultatory. Heart sounds are loud, rhythmic. The heart rate is 70 beats per minute, no pathological murmurs are heard.

The pulse is rhythmic, weak filling and tension. BP - 120/70 mm Hg

Digestive system.

The tongue is moist and clean. Zev normal color. The shape of the abdomen is normal. There is no visible peristalsis.

On superficial palpation, the abdomen is soft, there are no areas of increased skin sensitivity; discrepancies of the rectus abdominis muscles, the phenomenon of "muscle protection" is absent; Shchetkin's - Blumberg's symptom is negative.

With deep methodical palpation: sigmoid colon palpable in the form of a rumbling roller, painless; the caecum is palpable in the form of a cylinder 2 fingers thick, painless; ileum growls; the transverse colon moves up and down easily. There are no infiltrates or tumors.

The liver is palpable at the edge of the costal arch: the edge is sharp, the surface is smooth, painless. The size of the liver according to Kurlov is 9cm-8cm-7cm.

The gallbladder is not palpable.

The pancreas and spleen are not palpated.

Chair without features.

Urogenital organs.

Examination of the lumbar region revealed no redness or swelling. Voltage lumbar muscles no. The tingling symptom is negative on both sides. The bladder is not palpable. There are no dysuric disorders.

Endocrine system.

The thyroid gland is not visualized during examination. Secondary sexual characteristics correspond to age and sex, moderately developed. Hair according to female type.

Nervous system.

Clear consciousness is oriented in place, time and situation. Attention is stable, memory for current and past events is preserved. Thinking is logical, speech is consistent. Meningeal symptoms are negative. Pathology from CCI, sensory and motor areas was not revealed.

Gynecological study.

The external genital organs are formed correctly, with signs of hypoplasia. Hair on the female type. Hymen is ring-shaped.

The urethra and paraurethral passages are not changed. The mucous membrane of the entrance to the vagina is pink. Discharges are mucous.

per rectum :

the uterus in ante versio is smaller than normal, firm, mobile, painless.

The angle between the body and the neck is not pronounced. Appendages on both sides are not enlarged, their area is painless on palpation.

The vaults are free.

Preliminary diagnosis and its justification.

Based on the patient's complaints (of irregular and painful menstruation), the history of the disease (she has been sick since December 1998, when 10 days before the expected menstruation, violent bleeding began, for which she turned to the gynecologist. Treatment was carried out: gentamicin, Ca gluconate, vitamins, FTL On December 31, 1998, menstruation began on time.In February and March, menstruation was normal, only they were painful on the first 2 days, 6 days each, in March from March 10 to 16. On March 28, bleeding appeared again, was also accompanied by pain, periodic discharge were dark brown, periodically scarlet, continued until 16.04. - CaCl 2 electrophoresis. From 05.05.99, she took motherwort, cynarizine, tincture of eleutherococcus. Measured basal temperature 37.2 - 37.1. 5.05 menstruation began (ended on 11.05). usually, just as painful in the first 2 days, the results of a gynecological examination (the external genitalia are formed correctly, with signs of hypoplasia;

Per rectum: uterus in ante versio less than normal size, firm, mobile, painless. The angle between the body and the neck is not pronounced. The appendages on both sides are not enlarged, their area is painless on palpation), a preliminary diagnosis can be made:

Violation of menstrual function, puberty, according to the type of algoopsomenorrhea. Genital infantilism. Hypofunction of the ovaries.

Data from laboratory and instrumental studies.

- General analysis blood 14.05.99

red blood cells 4.0 x10 12 /l

Hemoglobin 114.7 g/l

Color indicator 0.9

platelets 245000

Leukocytes 8.7 x10 9 /l

Basophils 1%

Eosinophils 2 %

Neutrophils: Myeloc. ---

Young ---

stab 3 %

Segmented 53 %

The value of anamnesis for the diagnosis of gynecological diseases is extremely high. The female genital area is very closely connected with other organs and systems; its pathology can never be separated from the whole organism. IP Pavlov and his student A. G. Ivanov-Smolensky attached great importance to the anamnesis. Starting to collect an anamnesis of a gynecological patient, it is necessary to learn how to evaluate various complaints and symptoms. To collect an anamnesis with the greatest completeness and expediency, it is best to use a specific scheme that is included in the clinical history of the disease. Gynecological Clinic of the State Pediatric medical institute used a special case history form, which has a history chart filled out when receiving inpatients and outpatients ( the gynecological examination form will be discussed in detail in the next article.).

Let us dwell a little more on certain issues of the anamnesis and medical history of a gynecological patient as a whole. From passport information Special attention should be given to the age of the patient, as it matters in the age-related pathology of a woman, as well as for rational therapy, which at different ages can be different. Of great importance is the profession, as some types of gynecological diseases are associated with a particular profession.

From the anamnesis of the disease, the main questions of the doctor are the following two: 1) what the patient complains about (it is necessary to accurately determine the nature and essence of the complaints); 2) when the disease began, how long he considers himself sick. Further details about this disease are found out after the anamnesis of life, family anamnesis and a survey about the main functions of the woman.

From the anamnesis of life, they find out the living conditions in which the woman is located, diseases suffered in childhood, suffered general, gynecological, postpartum and venereal diseases; in addition, it is necessary to find out whether there were any serious and social dangerous diseases husband (alcoholism, tuberculosis, syphilis).

Then they move on to the anamnesis of the so-called "basic functions" of a woman, of which there are four.

1. First, they stop at the anamnesis of the menstrual function, and be sure to find out the time of the onset of the first menstruation. Next, they ask if menstruation was immediately established, how they proceeded - cyclically or intermittently; after how many weeks they came and how many days they lasted; were painful or painless. Late onset of menstruation and long breaks between them indicate a general underdevelopment of the woman's body or an underdevelopment of the genital organs. You should also find out if the periods have changed after marriage (which happens, for example, when infected with gonorrhea). Finally, from the anamnesis, the period of the last menstruation is clarified. In the elderly, they find out the time of occurrence of menopause or menopause and the characteristics of the course of the latter.

2. When asking a woman about the generic function, you should find out the total number of pregnancies, how many of them ended in childbirth and abortion; whether there were premature births, artificial and spontaneous abortions; when was the last pregnancy (birth or abortion); were there any complications of pregnancy, childbirth or abortion, which ones; number of children. A large number of pregnancies, especially those ending in abortions, are typical for patients with cervical cancer, a small number or infertility - for patients with uterine fibroids. Multiple induced abortions can cause infertility and inflammatory diseases of the genital organs.

3. The nature of the discharge - the excretory function - from the urethra, cervical canal, vestibular glands, vagina and uterus is considered pathological in cases where normal discharge are produced in large quantities (hypersecretion) or have a bad smell, or if pus, blood, serous fluid is mixed with the whites. - From the anamnesis, the prescription of this suffering is clarified, whether the discharge of linen is stained, which was the treatment of whites.

4. Anamnesis of sexual function is especially important in patients with neuroses, frigidity, uterine fibroids, inflammatory processes genitals. It turns out whether there is sexual desire (libido), orgasm and sexual satisfaction. It is also important to find out if there are pains and contact bleeding during sexual intercourse, as well as the method of contraception, paying attention to coitus interruptus, if used.

After receiving this information, we can assume that the anamnesis is largely collected. Next, you need to collect additional anamnesis regarding the functions of the bladder and intestines (especially the rectum); their incorrect function affects the position of the genital organs and their function. The anamnesis of the four functions of the female body facilitates further more detailed questioning about this disease. The patient must give detailed information about her disease, its clinical course, therapy, etc., which may be important for the correct diagnosis and further treatment.