Gynecologic History and Examination of the Patient

Abstract

Gynecologists are primary care providers for women. It is very important that a complete, comprehensive history and physical examination are performed and that every aspect of the patient’s health is addressed during the gynecologic visit. The patient interview should include gynecologic and obstetrical histories, as well as past medical, surgical, family, and social history. Once an overview of the patient’s health history is completed, focus can then be turned into specific complaints. In gynecology, these often are vaginal complaints, abnormal uterine bleeding, contraception counseling, fertility issues, urinary incontinence and prolapse, menopausal symptoms, or problems during intercourse. Attention should be also placed on complaints that can be associated with increased risk for gynecologic malignancies. Physical exam will then complete the encounter. The exam is focused on the patient’s chief complaint but should also include a general overview. At this time, appropriate screening testing can be performed and specific issues addressed. The goal of the gynecologic visit is to address all of the woman’s concerns, to obtain significant information that will guide diagnostic testing and treatment recommendations, and to develop a relationship between the practitioner and patient that will benefit the patient’s health status and future well-being.