What is a clinical examination?
The clinical examination is a core, routine part of the gynaecological assessment. As a clinician involved in the teaching of doctors in training and specialists seeking to increase their skills, when they are presenting (providing information about) a patient, it is natural to ask, ‘what did you find on clinical examination?’ It might surprise you the number of times that a history is taken and a differential diagnosis made without an examination being performed. In context it is akin to reading a recipe for a meal, preparing the table to eat but not actually cooking the food! It should not be a case of was an examination performed, in most cases the question should be why was an examination not performed?
Examination in the office
A clinical examination is the physical inspection of a patient or parts of her body, in order to verify health or diagnose disease.
Examination under anaesthetic
Can I suggest that if you go to your doctor about a new complaint or a change in the presentation of an existing complaint – expect to be examined, and if you are not examined, speak up and ask, ‘why not?’
What does a basic gynaecological examination involve?
Your general appearance is important to your doctor as it may give some indication as to your general health. General demeanour, evidence of anaemia or tremor, abnormality of gait or speech, shortness of breath, protruding eyeballs, estimation of body mass index (BMI) are some of the features that might lead your doctor to ask more specific questions, perform additional examinations or organise further investigations. It may not always be apparent how this might relate to your presenting complaint. Sometimes it does and at other times it may be a significant incidental finding. Feel free to ask you doctor why any particular question is being asked.
When doctors examine the abdomen, they look at it as the upper abdomen and lower abdomen or in quadrants; right and left upper quadrants and right and left lower quadrants. Assessment of the renal angles are also made by palpating the side parts of the back, below the ribs. The sequence of examination is; inspection, palpation, percussion and auscultation (look, press, tap, listen). Scars, skin lesions, tenderness, guarding, the presence of masses and sounds suggestive of fluid within the abdomen are all sought.
The pelvic examination has three components; visual inspection of the external genitalia, speculum examination and bimanual examination. The speculum examination is a visual examination using a speculum in order to facilitate a view of the internal genitalia; vaginal walls, cervix, urethral orifice and forchette. During the visual inspection and speculum examination you may be asked to cough as this increases abdominal pressure and drives down the pelvic organs to make prolapses or urinary incontinence more obvious. During the bimanual examination, one hand is placed on the lower abdomen and two fingers of the other hand are placed in the vagina. The uterus (if present) is compressed between the examining hands to assess its’ size and mobility. The same technique is used to assess the adnexal areas for tenderness or masses.
Examination under anaesthetic
The vast majority of clinical examinations will take place with you awake in the doctors office. However some examinations will need to be done under a general anaesthetic or sedation in an operating theatre.
Examination with the patient awake not possible or limited by:
- Poor vaginal access.
- Unacceptable discomfort.
- Poor view related to habitus (size and shape).
Examination whilst patient awake thought not to expose the extent of the presenting signs:
- Prolapse – the true extent of a prolapse in the woman examined whilst awake is often much less than when she is examined under anaesthetic. This is because there is a natural instinct to contract the muscles supporting the pelvic floor during an examination and this will have the effect of reducing any prolapse present.
- The true degree of prolapse will determine the type of surgery offered to the patient and allows a more comprehensive discussion about the options for further management to take place.
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