history taking obs/gynae

 HISTORY TAKING OBS/GYNAE

-        By Mohit Garg

1.      Biodata of the patient

2.      Chief complaints

3.      Menstrual history

4.      Obstetrical history

5.      Gynaecology history

6.      Past history

7.      Family history

8.      Nutritional history

9.      Social history

10.   GPE

11.   Systemic examination

Biodata of the patient:

Name, age, sex, address, phone number, date, religion, marital status, pregnant or not, LMP, EDD (calculated from the last menstrual period using Naegele’s rule. Add 9 months and 7 days to LMP)

Chief complaints

What is the problem that brought you to the hospital/clinic?

Some common presenting complaints include;

◘   Bleeding

◘   Abdominal Pain

◘   Hypertension

◘   Physiological complaints due to pregnancy

History of Presenting Complaint

Often there will be overlap between the history of the presenting complaint and the history of the current pregnancy.

Onset – when did the symptom start? / was the onset acute or gradual?

Duration – minutes / hours / days / weeks / months / years

Severity – e.g. if symptom is vaginal bleeding – how many sanitary pads are they using?

Course – is the symptom worsening, improving, or continuing to fluctuate?

Cyclical – do symptoms have any relationship to the menstrual cycle?

Intermittent or continuous? – is the symptom always present or does it come and go?

Precipitating factors – are there any obvious triggers for the symptom?

Relieving factors – does anything appear to improve the symptoms e.g. an inhaler/?

Associated features – are there other symptoms that appear associated e.g. fever / malaise?

Previous episodes – has the patient experienced these symptoms previously?

Key gynaecological symptoms:

Abnormal vaginal discharge – suggestive of infection

Vaginal bleeding – menorrhagia / intermenstrual/ post-coital / post-menopausal

Vulval itching / discomfort / skin changes

Abdominal / pelvic pain – dysmenorrhea / dyspareunia

Other relevant symptoms:

Urinary symptoms – frequency / urgency / dysuria

Bowel symptoms – change in bowel habit / pain on defecation

Fever – pelvic inflammatory disease – e.g. chlamydia

Tiredness / fatigue – anaemia – often occurs alongside menorrhagia

Weight loss – may suggest malignancy

Abdominal distension – uterine / ovarian malignancy

Pain – if pain is a symptom, clarify the details of the pain using SOCRATES

Site – where is the pain

Onset – when did it start? / sudden vs gradual?

Character – sharp / dull ache

Radiation – does the pain move anywhere else?

Associations – other symptoms associated with the pain

Time course – worsening / improving / fluctuating / time of day dependent

Exacerbating / Relieving factors – anything make the pain worse or better?

Severity – on a scale of 0-10, how severe is the pain?

History of Current Pregnancy

The history of current pregnancy should ideally be considered by the different trimesters to date. This will be useful for understanding common issues that arise at each stage, and also determining appropriate antenatal care and management.

Menstrual history

·        Age of menarche (medical term for a woman's first menstruation, commonly known as her first period)

·        Last menstrual Period (LMP) - defined as the first day of the LMP

·        Cycle length and regularity – e.g. 5-day period occurring regularly every 28 days.

·        Flow – heavy / light – number of sanitary towels / tampons can be useful to estimate loss. Flow is heavy if the number of soaked tampons or pads is sixteen or more for the entire duration of your period (or eight fully soaked maxi tampons or pads).

·        Ask about passage of clots.

·        Menstrual pain – use the SOCRATES method shown above to assess menstrual pain

·        If post-menopausal, at what age they go through menopause?

General questions

·        Estimated delivery date and approximate Gestational Age.

·        Any concerns about your pregnancy

·        What are your expectations regarding your pregnancy

First Trimester

·        Further details regarding menstrual history (as below)

·        Was the Pregnancy planned/unplanned

·        Ask about amenorrhoea

·        How was the pregnancy confirmed (herself, pregnancy test or US)?

·        Signs and symptoms of pregnancy.

·        Any booking and how many visits. Suggested schedule for antenatal visits: -

a)      1st visit: Within 12 weeks—preferably as soon as pregnancy is suspected—for

b)     registration of pregnancy and first antenatal check-up

c)      2nd visit: Between 14 and 26 weeks

d)     3rd visit: Between 28 and 34 weeks

e)     4th visit: Between 36 weeks and term

f)       It is advisable for the pregnant woman to visit the MO at the PHC for an antenatal check-up during the period of 28–34 weeks (third visit). Besides this, she may also be advised and guided to avail investigation facilities at the nearest PHC/CHC/FRU.

·        Ask about folic acid tablets (Folic acid is most important before and in the first few weeks of pregnancy, because it prevents some birth defects)

·        Identify whether there were complications during any previous pregnancy/confinement that may have a bearing on the present one.

·        Ask about TT injection (she needs to take 2 injections (at first visit, and second 4 weeks later). If she has received the booster within last 10 years, then she needs to take only one injection). If a mother received 2 TT doses in the last pregnancy and mother gets again pregnant with in 3 y than only one dose of TT is recommended and that dose is called booster dose.

·        How/has the pregnancy been dated (e.g. dating Ultrasound Scan)?

·        What tests and scans have you had to date?

·        Current medical illnesses and medications.

·        Ask about micturition frequency (increased frequency in first trimester, reduced in second trimester and increased again in third trimester).

·        Ask about X-ray exposure

·        Ask about BPV(bleeding; various causes of bleeding 1^st trimester are ), DPV(discharge), LPV (leaking; Women with pre-mature rupture of membranes, usually experience a painless gush of fluid leaking out from the vagina, but sometimes a slow steady leakage occurs instead).

Second Trimester

·        Ask about amenorrhoea

·        Any problems during second 3 months?

·        Ask about pica - An urge to eat non-nutritive substances, a condition called pica, can occur in pregnant women with low iron levels.

·        Date of quickening (first fetal movements; between 18 weeks and 22 weeks or around 5th month).

·        Ask about PIH – ring tightening, edema, headache, blurring, epigastric pain.

·        Last visit to the doctor?

·        Ask about iron (red in colour) and folic acid (white in colour) tablets.

·        Placental localization and baby growing well

·        Has an Ultrasound scan (e.g. morphology scan) been done?

·        Blood tests to date?

·        Blood pressure?

·        Ask about quickening.

·        Change in weight?

·        Bleeding, vaginal discharge

·        Ask preeclampsia (Rapid weight gain caused by a significant increase in bodily fluid Abdominal pain, Severe headaches, Change in reflexes, Reduced urine or no urine output, Dizziness, Excessive vomiting and nausea, Vision changes) or eclampsia.

·        Ask about gestational diabetes [Increased levels of certain hormones (including cortisol, estrogen, and human placental lactogen) can interfere with your body's ability to manage blood sugar. This condition is called "insulin resistance." Usually your pancreas (the organ that produces insulin) is able to compensate for insulin resistance by increasing insulin production (to about three times the normal amount). If your pancreas cannot sufficiently increase insulin production to overcome the effect of the increased hormones, your blood sugar levels will rise and cause gestational diabetes] - Blurred vision, Fatigue, Frequent infections, including those of the bladder, vagina, and skin, Increased thirst, Increased urination, Nausea and vomiting, Weight loss despite increased appetite

·        Ask about urinary frequency.

·        Ask about X-ray exposure or drug intake.

Third Trimester

·        Any issues after the first 6 months of your pregnancy?

·        Bleeding, vaginal discharge, urinary problems, labour pain.

·        Blood pressure

·        Tdap vaccine can be given at any point during pregnancy, though the preferred timeframe is between 27 and 36 weeks of gestation to protect baby from whooping cough.

·        Glucose levels

·        Again ask about X-ray exposure, drug intake.

·        Test results

·        Any plans or ideas about method of delivery.

Past Obstetric History

Gravidity: the number of times a woman has been pregnant, regardless of the outcome.

Parity: the number of times a female has given birth to a baby or fetus crosses period of viability, i.e., 28 weeks but more recently 24 weeks.

There are many different methods and protocols by which Gravidity and Parity are denoted, please be aware of your local policy and documentation guidelines.

A simple system commonly used in the UK is;

GPx+y

where

G= Gravidity, P = Parity: X = (any live or still birth after 24 weeks);

Y = (number lost before 24 weeks)

A woman who has never given birth is a nullipara, a nullip, or para 0.

A woman who has given birth two or more times is multiparous and is called a multip.

A woman in her first pregnancy and who has therefore not yet given birth is a nullipara or nullip. After she gives birth she becomes a primip.

A woman who has given birth once before is primiparous, and would be referred to as a primipara or primip.

Details of each pregnancy (first to last):

•     Dates of deliveries
•       Length of pregnancies
•        Singleton/twin and so on
•        Induction of labour/Spontaneous
•        Mode of Delivery
•        Weight of babies
•        Gender of babies
•       Complications before, during and after delivery
•        Any abortion
• \       Number of miscarriages, terminations and/or ectopics – with appropriate details.
•        This question should be asked as some patients will not consider the above situations as pregnancy.
•        Any difficulties conceiving and any treatment/management to date for sub-fertility.

Past Gynaecological History

•       If it hasn’t been so already, you should first gain a Menstrual History as appropriate.
•       Age of menarche
•       1st day of last menstrual period
•       Duration and regularity of normal cycle (cycle length)
•       Flow: heavy/light, clots, number of tampons/pads used
•       Pain
•       Last Cervical Smear (Pap Smear): when and results.
•       Any Gynaecology Surgery?
•       Treatment or investigations for; ectopic pregnancy, pelvic inflammatory disease, infertility
•       This may be an appropriate place to take a Sexual History (see sexual history for further details).
•       Any contraceptives in use

Past Medical & Surgical History

Current or past illnesses

•     Hypertension
•       Diabetes
•       Epilepsy
•       Thyroid (hypo or hyper)
•       Thromboembolic disease
•       Asthma
•       Hospital Admissions: when, where and why.
•       Any surgical procedures

Family history

•     Similar complaints or any chronic disease
•     History of twin
•     Congenital abnormality
•       Any genetic disease

Nutritional history

Calories consumed and calories required.

Social history

• Personal History
• Occupation
• Relationship Status
• Diet/physical activity
• Smoking (amount, type, duration, any trials of quitting)
• Alcohol (healthy alcohol use: male is 14 units/week and female 7 units/week) (but not >4/session and >2/session)
• Drug use
• Living Situation
• Travel History

Occupation, Support network, Smoking, Alcohol, Marital status, KPS

GPE and systemic examination

General Considerations:

General appearance, depression, pallor, jaundice, cyanosis, edema, varicose veins and vitals

Comment on hair, face, neck, eyes, tongue

Systemic examination:

·        General - weakness, night sweats, anorexia

·        CVS - Chest pain, shortness of breath, cyanosis, cough/sputum

·        Respiratory rate – sputum, cough, haemoptysis, chest pain, wheezing, tachypnoea.

·        Abdominal – any surgical scars, appetite, nausea, vomiting, bowel habits, abdominal pain, haematemesis, fetal movements, cutaneous pregnancy signs [linea nigra (dark vertical line that appears on the abdomen in about three quarters of all pregnancies), striae albicans (white scar tissue marks after delivery) and striae gravidarum (stretch marks)], fetal heart sounds

Fundal height – by palpation if less than 20 weeks and by tape is >20 weeks. Measure it from the                                              top of the mother's uterus to the top of the mother's pubic symphysis.

Th is indicates the progress of the pregnancy and foetal growth. Th e uterus becomes an abdominal organ aft er 12 weeks of gestation. Th e gestational age (in weeks) corresponds to the fundal height (in cm) aft er 24 weeks of gestation. Remember that while measuring the fundal height, the woman’s legs should be kept straight and not flexed. Divide the lower abdomen (below the umbilicus) into three parts, with two equidistant lines between the symphysis pubis and the umbilicus. Similarly, divide the upper abdomen into three parts, again with two imaginary equidistant lines, between the umbilicus and the xiphisternum.

Leopold’s maneuver

First maneuver: Fundal Grip

While facing the woman, palpate the woman's upper abdomen with both hands. A professional can often determine the size, consistency, shape, and mobility of the form that is felt. The foetal head is hard, round, and moves independently of the trunk while the buttocks feel softer, are symmetric, and the shoulders and limbs have small bony processes; unlike the head, they move with the trunk.

Second maneuver: Umbilical Grip

After the upper abdomen has been palpated and the form that is found is identified, the individual performing the maneuver attempts to determine the location of the foetal back. Still facing the woman, the health care provider palpates the abdomen with gentle but also deep pressure using the palm of the hands. First the right hand remains steady on one side of the abdomen while the left hand explores the right side of the woman's uterus. This is then repeated using the opposite side and hands. The foetal back will feel firm and smooth while foetal extremities (arms, legs, etc.) should feel like small irregularities and protrusions. The foetal back, once determined, should connect with the form found in the upper abdomen and also a mass in the maternal inlet, lower abdomen.

Third maneuver: 1st pelvic grip

In the third maneuver, the health care provider attempts to determine what foetal part is lying above the inlet, or lower abdomen. [2] The individual performing the maneuver first grasps the lower portion of the abdomen just above the pubic symphysis with the thumb and fingers of the right hand. This maneuver should yield the opposite information and validate the findings of the first maneuver. If the woman enters labor, this is the part which will most likely come first in a vaginal birth. If it is the head and is not actively engaged in the birthing process, it may be gently pushed back and forth. The Pawlick's Grip, although still used by some obstetricians, is not recommended as it is more uncomfortable for the woman. Instead, a two-handed approach is favoured by placing the fingers of both hands laterally on either side of the presenting part.

Fourth maneuver:2nd Pelvic Grip

The last maneuver requires that the health care provider face the woman's feet, as he or she will attempt to locate the fetus' brow. The fingers of both hands are moved gently down the sides of the uterus toward the pubis. The side where there is resistance to the descent of the fingers toward the pubis is greatest is where the brow is located. If the head of the fetus is well-flexed, it should be on the opposite side from the fetal back. If the fetal head is extended though, the occiput is instead felt and is located on the same side as the back.

·                 
            Urinary system – frequency, dysuria, nocturia, loin pain

·        
            CNS – headache, tremor, fits, unconsciousness.   

Gynaecologic examination includes examination of the breasts, abdomen, and pelvic organs. However, many women see their gynaecologist as their primary health care provider, and will seek a complete physical examination when they come into the office for their gynaecologic evaluation. In addition, many gynaecologic problems have symptoms that involve other organ systems. Consequently, the gynaecologist must be prepared to perform a general physical examination competently.

      Timing and Frequency of Examinations

Genital examinations are often part of routine well-baby and well-child paediatric care. A genital examination should be performed if a child has a symptom in the genital area (e.g., vulvar itching) or there any concerns about a developmental problem (e.g., early development of secondary sexual characteristics).

Adolescents often benefit from a visit to a primary care provider to discuss any health care concerns they may have, and to ensure that appropriate preventive primary care is administered (e.g., immunizations, blood pressure checks, and general physical examinations, as well as counselling regarding smoking and safety habits). This visit will hopefully pave the way for a relaxed relationship between the adolescent and the provider when it is time for the first pelvic examination. A pelvic examination is recommended at age 18 or with onset of sexual activity, whichever occurs first.

Hormonal contraception can be provided safely based on a careful review of a patient’s medical history and measurement of the patient’s blood pressure7. Unless the patient has symptoms, the pelvic and breast examinations and screening for cervical neoplasia and sexually transmitted diseases can wait until a subsequent visit. Especially in the adolescent population it is important to not always require tests and procedures prior to an initial prescription for hormonal contraception. These patients may be reluctant to undergo examination, and an unintended pregnancy may result, with all of its inherent risks.8

The recommended interval for examinations during the reproductive years varies with a woman’s health and risk status. Women should undergo annual cytologic screening for cervical intraepithelial neoplasia beginning at age 21 or 3 years after the onset of sexual activity, whichever comes first. Beginning at age 30, cervical smears may be obtained every 3 years in the selected low-risk patient. Women at risk for cervical intraepithelial neoplasia should continue to have annual cervical cytologic screening. Screening may be discontinued at age 65 if there is no history of abnormal smears or HPV, or at any age after hysterectomy for benign disease if the patient has not previously had abnormal cervical cytology. Whether or not a smear for cervical cytology is performed, many women benefit from annual well-woman examinations that include assessments of height, weight, and blood pressure, as well as examinations of the thyroid and breasts, and the other components of the pelvic examination. Women receiving contraceptive hormone therapy should be assessed at least annually.9

Women’s Experiences and Gynaecologic Examinations

Women are often apprehensive about undergoing a pelvic examination. A previous examination that was not a good experience contributes to even more anxiety. Women feel vulnerable and exposed during this examination. The positioning necessary for the examination creates a significant imbalance of power in the patient/provider interaction, and carries sexual connotations for many women. The practitioner may unintentionally use words or actions that the patient may find threatening or offensive. The provider may feel that the interaction was satisfactory, but the patient may feel completely the opposite. On the other hand, if a woman is at ease with the examination experience, she is more likely to spontaneously contribute information that may prove valuable in her evaluation.

Patients will have a more positive experience if they feel that adequate time was allowed for their visit and that the practitioner was prepared to answer questions. A study of adolescents' views about their first pelvic exams showed that a positive experience was associated with a sense of control during the examination.  This depended on a thorough explanation of the procedure before it was undertaken, allowing the patient to participate in decision making, and receiving assurance that the exam could be discontinued at any point.10

Most patients indicate that they are more comfortable if the provider talks to them during the examination. Silence can cause the patient to think that something is wrong. If the provider explains what is coming next, maintains eye contact as much as possible, and comments on findings, the patient is more likely to feel relaxed and safe. Some women will feel more at ease if they are allowed to view their own anatomy by using a hand-held mirror during the examination. Warming instruments and trying to be as gentle as possible during the examination are good habits. Some women desire an attendant to be present during their examination but many prefer not. Ideally a woman is empowered to choose whether a chaperone is present during her examination. There are situations where the provider must have a chaperone present for examinations due to liability or security concerns. If so, this should be explained to the patient.11

The examiner should be conscious of patient behaviours that suggest anxiety during the examination. These include holding hands, covering or shutting the eyes, placing hands on shoulders, hands covering the pelvis, placing hands on legs, or hands holding the table. Such behaviours signal the need for a more careful or respectful approach. The examiner may suggest techniques to promote relaxation, such as slow exhalation, and may provide more information about what is coming next in the examination and what the patient may feel. The provider should endeavour to individualize the consultation and examination style so that it meets the needs of the patient.12, 13

Patient Positioning

The pelvic examination is usually performed with the patient lying supine on an office examination table with the knees flexed, and with the feet in supporting stirrups. Some examination tables have supports that fit behind the knees instead. Electric examination tables are available, with which the patient’s head can be lowered from a seated position; these can be advantageous for the elderly or for patients with mobility problems. The patient’s head is often elevated with a pillow, or by slightly elevating the head of the examining table. This allows better eye contact between the practitioner and the patient and may help the patient to relax.

Equipment

In order to perform a pelvic examination, the practitioner should have a good light source, non-sterile gloves, a speculum of proper size, and water-soluble lubricant. A variety of the most commonly used specula, materials with which to obtain cervical cytologic samples, fixative, and large cotton-tipped swabs should be immediately available in the examination room. Swabs and transport media for the collection of samples for Neisseria gonorrhoea, Chlamydia trachomatis, and saline wet mounts, as well as pH paper should be on hand.

Performance of the Gynaecologic Examination

BREAST EXAMINATION.

The breast examination is included in a routine gynaecologic examination. The technique for breast examination is outlined in another chapter. The health care provider should instruct the patient about how to undertake a breast self-examination.

EXAMINATION OF THE ABDOMEN.

Examination of the abdomen is likewise included in the general gynaecologic examination. The abdomen should be examined utilizing the standard techniques of inspection, auscultation, percussion, and palpation. The contour of the abdomen and appearance of the skin should be noted. Auscultation aids in the assessment of intestinal peristalsis (bowel sounds) and in the detection of abdominal bruits. Percussion is utilized to determine the size of abdominal and pelvic structures such as the liver and masses, as well as any abdominal fluid collection such as ascites. Percussion is also useful for assessing abdominal and pelvic tenderness. Finally, palpation is performed to assess for tenderness, organ enlargement, and masses.

If tenderness is noted, the examiner should assess for involuntary guarding and rebound tenderness. In addition, it may be helpful to ask the patient to raise her head from the examination table so as to flex the rectus abdomens muscles. Tenderness localized to the abdominal wall will typically worsen with this manoeuvre.

PELVIC EXAMINATION.

External genitalia. There can be a tendency to focus on insertion of the speculum for obtaining cytology specimens. The examiner should always remember to inspect the external genitalia first for normalcy of appearance and hair distribution. Any lesions or developmental abnormalities are noted. Hormonal abnormalities may cause changes in the external genitalia, such as clitoromegaly. States accompanied by low levels of estrogen are associated with atrophy of the mucosae. The skin should be inspected and palpated for superficial and subcutaneous lesions.

The Bartholin’s (greater vestibular) gland openings are located at approximately the 5 and 7 o’clock positions, just lateral and posterior to the vaginal orifice. They may be visible, but the normal Bartholin’s gland is not palpable. The Skene’s (paraurethral) glands are likewise not palpable in the healthy state. The urethra is inspected for the presence of caruncle and other findings.

Vagina and cervix. The vagina is inspected with the use of a speculum. There are many different sizes of specula varying both in length and width. The largest size that is comfortable allows the best visualization. The examiner should be ready to switch to a narrower or shorter speculum if the patient is uncomfortable with the size selected.

Speculum insertion is more comfortable if the instrument is warmed. The speculum can be moistened with warm water, which does not interfere with the results of cultures, cytology, or wet mount. Lubricants can alter the results of these studies, and should only be used if none of these studies will be undertaken. The examiner may exert gentle downward (posterior) pressure at the introitus with one or two fingers before inserting the speculum. The speculum blades can be inserted at an oblique to horizontal angle but should never be inserted vertically so as to avoid the sensitive sub urethral area. Utilizing steady posterior pressure, the blades are advanced to the vaginal apex. The speculum can then be gently opened to expose the cervix. Sometimes a gentle rocking motion will allow the cervix to come into view.

The vagina and cervix are inspected for lesions. The vagina is also inspected for the presence or absence of rugae to assess the level of estrogen present. The examiner assesses any vaginal discharge that is present for normalcy in appearance, colour, consistency, and odour. Physiologic vaginal discharge is scant in amount, flocculent, and white. The pH of the normal vagina is less than 4.2. Normal cervical mucus is clear.

Samples are taken for cervical or vaginal cytology. Cervical cytology should include a sample from the ectocervix taken with a spatula and a sample from the endocervical canal taken with a brush. Cervical cytology should be fixed immediately after obtaining the sample in order to avoid air-drying artefact. In the absence of a cervix, a spatula can be used to obtain a smear from the vaginal cuff.  If a liquid-based technique is employed for cytology, a plastic "broom" is used to collect the specimen.

If indicated, samples are then obtained for cervical cultures and vaginal wet mount. Swabs used to collect samples for cervical cultures should be left in the endocervical canal for 15 to 30 seconds. A swab of vaginal sidewall secretions is placed in normal saline for direct microscopic examination (wet mount) to evaluate for vaginitis. The pH of vaginal secretions can be assessed with pH paper.

The vagina is inspected for lesions as the speculum is withdrawn, again with care to avoid anterior discomfort.

If indicated, the examiner now proceeds to evaluate vaginal wall relaxation and uterine prolapse. This can be done by removing the anterior blade of the speculum and using the posterior blade as a retractor, or by using one’s hand as the posterior retractor. The integrity of the vaginal walls is examined throughout 360 degrees, and at the apex. The patient may be asked to increase intra-abdominal pressure with the Valsalva manoeuvre to accentuate the findings. Examination can also be performed with the patient standing to better assess the integrity of pelvic support when the patient is upright.

Bimanual examination. Typically, the bimanual examination is performed with the aid of lubricating jelly. The examiner usually places two fingers in the vagina and uses the opposite hand to palpate the lower abdomen. Sometimes only a single digit is placed in the vagina for patient comfort. The examiner palpates the vagina, cervix, uterus, adnexa, and surrounding structures by elevating structures with the vaginal hand and palpating in a downward fashion with the abdominal hand. Tenderness with lateral movement of the cervix (cervical motion tenderness) is assessed, as well as the size, mobility, position and contour of the uterus. The adnexa are palpated. Any masses that are appreciated are assessed for size, location, mobility, tenderness, and contour. The posterior cul-de-sac and utero-sacral ligaments are checked for nodularity and masses.

Rectovaginal examination. Some believe that a rectal examination is an important element of every gynaecologic examination. Others feel that it is only necessary in the age group for whom colon cancer screening is recommended for routine preventative health care (beginning at age 50). A reasonable middle-ground approach involves including a rectovaginal examination when the bimanual examination alone has been insufficient to fully assess the pelvic anatomy, when one suspects endometriosis or a pelvic mass, or if there are symptoms attributable to the rectal area.

The examiner inserts an index finger into the vagina, and utilizing lubricant, inserts the middle finger into the rectum. The examiner palpates the rectovaginal septum and again places the opposite hand on the patient’s lower abdomen to palpate the previously assessed structures. The uterosacral ligaments may be palpated more easily with the rectovaginal examination than the bimanual examination. The rectum is assessed for masses.