CC JUANICO, CLAREEN MAE T.

17/07/2020

COMPREHENSIVE HISTORY TAKING AND PHYSICAL EXAMINATION IN OB-GYN PATIENTS

I. HISTORY TAKING FOR OB AND GYNE PATIENTS it includes the following:

General Data Sexual History

Chief Complaint Family Planning History
History of Present Illness Menstrual History
Past Medical History Obstretical History
Family History Gender-Based Violence
Social and Environmental History Prenatal History (for OB Patients)

 Common Chief complaints in OBGYN patients:

 Menstrual Problems (Dysmenorrhea, Amenorrhea, Oligmenorrhea, Hypermenorrhea,
Menorrhagia, Metrorrhagia, and Menometrorrhagia) Dysmenorrhea- painful menstrual
 Abnormal vaginal discharge (Bloody, Purulent, Curd-like characteristic of yeast/fungal infection,
Foul smelling)
 Pelvic/abdominal pain
 Vulvar/pelvic masses
 Urinary problems
 History of the Present illness should contain the Chief Complaint’s: onset, duration, severity,
precipitating factors, occurrence in relation to other functions, and previous similar symptoms
(diagnosis and management). It should also contain the effects of the chief complaint to the daily
life of the patient, if there were intervention done and if there was a relief, and role of other
stresses to the chief complaint
 Past Medical History, Family History, Social and Environmental History
 Sexual History contains the following:
 Coitus:
o Coitarche: when was the patient’s first sexual intercourse?
o Frequency (how many times did the patient do it?)
o Is there Post coital bleeding?
o What was the sexual response of the patient
 Habits (Does the patient perform douching?)
  Partners
o How many partners does the patient have?
o What is the patient’s gender preference
 Infertility (How long has the patient been infertile? how was it managed?)
 STI (Does patient have STI, what type? Gonococcal, Chlamydial, Herpes, Syphilis, etc)
 Family Planning History
 Contraception: (what type of contraception is used by the patient? How long has she been using
it? Is she compliant? Why is the patient using it? And were there complications?)
 Menstrual History (MIDAS)
 Menarche/menopause
 Interval (Check for Regularity)
 Duration of flow in days
 Amount (Is it light, moderate, or heavy? Is the pad fully soaked? how frequent does she
changes napkin)
 Symptoms with menses (Example: Dysmenorrhea, breast tenderness or post-menopausal
bleeding)
 LMP (LAST MENSTRUAL PERIOD) should also be noted
o First day of the last normal menstrual period
o Patient should be asked about the last NORMAL menstruation
o This is important for estimation of Age of Gestation and Expected date of delivery
 PMP (PAST MENSTRUAL PERIOD)
o Use to determine regularity
o Menstruation before the LMP
 Obstretical History
 GRAVIDITY: how many times have the patient been pregnant?
o Nulligravida- never been pregnant
o Primigravida- first time to be pregnant, regardless of outcome
o Multigravida- patient became pregnant 2 or more times, regardless of outcome
 PARITY (number of times that patient has given birth to a fetus with 24 weeks AOG or more,
regardless of outcome)
o Nullipara- never completed pregnancy that reached 20 weeks AOG
 o Primipara – given birth for the 1st time to fetus/fetuses (alive or dead), has reached ≥ 20
weeks AOG
o Multipara- given birth 2 to 5 times to fetus/fetuses (alive or dead) has reached ≥ 20
weeks AOG; not number of fetuses delivered (single, twins, or triplets)
 OB SCORE G_P_ (T_P_A_L_)
o G- Gravida
o P- Para
o T- Term Infants (> 37 weeks AOG)
o P- Preterm infants (20 to 37 weeks AOG)
o A- Abortions (<20 weeks)
o L- Living children
o G and P refers to the pregnancy
o TPAL refers to the number of fetuses/children
 Past Pregnancies
o Number and year when pregnancies occurred

o Outcome (AOG, mode of delivery)

o Delivery place and attendant

o Birth weight and status of baby (APGAR score of neonate)

o Complications (antepartum, intrapartum, postpartum)

o Tetanus immunization
 If patient is pregnant:
o Age of Gestation and Expected date of delivery should be determined.
o For AOG- days/ weeks from LMP is counted
o For EDD/EDC (Expected Date of Delivery/ Confinement): Naegele’s rule is used
o In Naegele’s rule: starting from LMP, 3 months are subtracted, 7days are added, plus
one for year. For months January to March, instead of subtracting 3 from the month,
add 9 months then proceed to adding seven on the date. Do not add 1 for year.
 Gender Based Violence (RADAR)
 Routinely ask about experiences of abuse as part of normal history taking.
 Provide medical management and document in the records all the instances of abuse (include
details of perpetrator
  Maintain privacy and confidentiality of patient
 R- Routinely screen ALL female patients, even children
 A- Ask direct questions
 D- Document findings
 A- Assess patient safety
 R- Review options and referrals
 Ask patient when violence started (time, date and location of abuse); details of who and how
injuries were inflicted; how frequently it occurs; and if alcohol/ drugs are involved.
 PRENATAL HISTORY (FOR OB PATIENTS)
 When, where did she start?
 With whom?
 Illnesses? Medications taken? Was there relief?
 Are Immunizations given?
 Vitamin supplementations given? Was patient compliant?
 Was patient exposed to hazards? To radiation?
 Were Laboratories taken?
II. PHYSICAL EXAMINATION FOR OBGYN PATIENTS
PE in OB GYN Patients include the following:
oVital Signs (BP, RR, CR/PR, Temperature, oHeart
Weight, BMI) oAbdominal and Pelvic
oGenerally Survey oExtremities
oHEENT, Neck oIntegument
oChest, Breasts and Lungs

In addition, there are specific Physical Examinations only performed in OB GYN patients:
1. GYN Physical Examination
Take note: PRIVACY, CONFIDENTIALITY and REASSURANCE for patient are important (especially if with
male examiners). A companion may be needed if the examiner is a male.
 BREAST EXAMINATION
 Inspection: Note for visible changes such as lumps, dimpling, nipple retraction
 Palpation
o Patient in sitting position
 o Pateint should raise one arm and the doctor should palpate the corresponding breast as
well as under the armpit to note for lumps, nodules or other abnormalities.
 Palpation of the breast may also be done while patient in supine position
o Patient in the supine position with a pillow supporting the ipsilateral hemithorax.
o Physician then gently palpates using the palmar aspect of the finger, the breast from the
ipsilateral side, then examine all quadrants of the breast from the sternum laterally to the
latissimus dorsi muscle and from the clavicle inferiorly to the upper rectus sheath.
o The breast then can be cupped or molded in the surgeon's hands to check for retraction.
o Checking for lymphadenopathy then is performed, the upper arm and elbow are
supported while the physician stabilizes the shoulder girdle.
o Using gentle palpation, the physician assesses all three levels of possible axillary
lymphadenopathy.
 ABDOMEN
 Inspection: Take note of shape, size, and symmetry of the abdomen. Check for any cutaneous
signs of pregnancy, surgical scars and fetal movement.
 Auscultation: listen for bowel sounds, for fetal heart beat if patient is pregnant.
 Percussion: check for fluid wave and flatulence.
 Palpation: palpate to check for uterine size, architecture, shape, symmetry, and consistency.
 Other masses and tenderness should also be palpated.
 GYNE PELVIC EXAMINATION
 Done to assess the reproductive organs, check for tumors and vaginal infections, determine if
patient is pregnant and for cervical cancer screening.
 Patient should be prepared first: bladder is emptied, proper draping, patient in supine or
lithotomy position, and pelvic area should be properly illuminated. Patient should be
covered, with the perineum as the only visible part. Patient should be positioned in dorsal
lithotomy position, legs are flexed and feet are rested in stirrups with buttocks extending
slightly beyond edge of examining table
 Examiner should also prepare: Examiner must face the patient; inform patient of the step by
step procedure and should have a gloved hand. Physician should sit in front of patient
between her legs, low enough to obtain a good vision of the genitalia and high enough to
maintain visual eye contact with the patient
  If with a Pediatric patient, ask for the assistance of the mother to sit the patient in a “Frog-
leg” or “knee-chest” position. Virginal or nasal speculum is used to visualize the internal
structures.
Parts of the Pelvic Exam
A. Inspection and palpation of external D. Internal examination
genitalia E. Bimanual examination
B. Speculum examination F. Rectal/rectovaginal exam
C. Pap smear G. Recto-abdominal examination
A. INSPECTION AND PALPATION OF THE EXTERNAL GENITALIA
 Visually inspect the vulva: take note of the skin and pubic hair pattern. Contour, swelling or
any abnormalities of labia majora, labia minora, Perineal body, and anal region should be
noted.
 Abnormal discharges from vaginal orifice should also be noted.
 Using the index finger and the middle finger of the gloved hand labia majora and labia minora
o Inspect and palpate epidermal and mucosa and check on the anatomic configuration of
labia minora, clitoris, urethral orifice, introitus, hymen, perineal body, and anus
o Physician may also palpate the Skene’s gland for abnormal secretion by milking
undersurface of urethra through anterior vaginal wall (milk like discharge may be due to
infection)
 Palpate for diseased Bartholin’s gland (at 5 and 7 position) with thumb on posterior part of
labia majora and index finger in the vaginal orifice. Masses or cysts are checked using the
thumb and forefinger.
 With the labia majora still separated ask the patient to bear down to palpate for: Cystocoele
(bulging of anterior vaginal wall); Rectocoele (bulging of posterior vaginal wall); and Pelvic
organ prolapse (descent of cervix/uterus into introitus)
B. SPECULUM EXAMINATION
 Vagina and cervix are inspected
o Speculum to be used should be in Proper size, warmed and lubricated.
o Introduce instrument into vaginal orifice with blades closed, oblique and pressed against
perineum, directed posteriorly. Insert speculum completely
o Rotate blades into horizontal position and once speculum is inside the vagina open blades
and maneuver speculum until cervix is visualized between blades
 o Gently rotate speculum around its long axis until all surfaces of vagina and cervix are
exposed and withdraw the speculum slowly
o Close the blades away from cervix and rotate to oblique position
o Use the “virginal speculum” for virgins and pediatric patients
 Inspect the vagina: check for presence of blood, if there is discharge, and mucosal
characteristics.
o Discharge should be described (type, amount, consistency, color, and odor)
o Mucosal characteristics should be described (color, lesions, vascularity, edema)
 Inspect the cervix: Mucosal characteristics, discharge, status of external os and
transformation zone, and presence of masses cysts or polyps should be noted.
o Discharge should be described (type, amount, consistency, color, and odor)
o Mucosal characteristics should be described (color, lesions, vascularity, edema)
C. PAP SMEAR
 Physician must identify first the transformation zone. Using Ayre's spatula or cotton, it is
inserted and placed at cervical os (with the longer end at endocervical canal and smaller end
rests on ectocervix). Spatula is then rotated 360 o. Sample collected is smeared evenly (in one
direction) on slide and fixed immediately.
D. INTERNAL EXAMINATION
 Physician is now standing in front of the patient.
 Speculum is first removed.
 To assess the cervix and vagina: thumb and small finger of gloved hand are abducted to spread
labia majora while the index and middle fingers are flexed into palm. Well lubricated Index and
middle fingers are introduced the vagina posteriorly near the perineum. Thumb is still
abducted while ring finger and small finger are flexed towards the palm. Lubricated fingers are
advanced along posterior wall until cervix is felt. Test strength of perineum by pressing
downward on perineum and ask patient to bear down. Tightness of introitus should also be
noted. Record abnormalities of structure or tenderness of vagina. Record the size, position,
shape, symmetry, architecture and consistency of the cervix. If patient is pregnant, cervix
consistency is like of the lips and if not it has a nose like consistency.

E. BIMANUAL EXAMINATION: for the assessment of the uterus and adnexa

  Physician remains in standing position in front of patient. Maintain index and middle fingers in
vagina. Place free hand on hypogastric area. Depress the perineum and rest the forearm of the
vaginal hand on the knee to gain extra length to reach the vagina. Relax the wrist and press
gently downward to sweep the pelvic structures towards the palpating vaginal fingers.
Evaluate the cervix (tenderness, position, architecture, consistency and mobility). Uterus may
also be evaluated (position, size, shape, consistency, mobility, tenderness and symmetry).
Evaluate tumors if present. Vaginal fingers are placed on right lateral fornix and abdominal
hand on right lower quadrant. Manipulate the hand on the abdomen to press downward
toward the vaginal fingers. Assess the right adnexa (where ovaries can be palpated). Fallopian
tubes are not palpable and normal ovaries are not often palpable. Evaluate tumors in the right
adnexa if present (note for the location, size, consistency, tenderness and mobility). Lastly,
repeat the procedure to assess the left adnexa.
F. RECTAL/RECTOVAGINAL used for higher assessment of pelvis and cervix.
 Inform patient that the procedure may cause discomfort and make her feel like moving her
bowels. Insert or keep the index finger in the vagina and insert the middle finger in the rectum.
Then repeat maneuvers as performed in bimanual exam. Assess the following: area behind the
cervix, posterior portion of the uterus and status of recto-vaginal septum. If there is
malignancy, rectovaginal septum is thickened. Also used to assess the pelvic organs, perineal
membrane, integrity of perineum and competence of rectal sphincter.
G. RECTO-ABDDOMINAL EXAM (assessment of the pelvic organs in virgins with intact hymen)
 Similar to IE except that assessment is via the rectum
 Physician may also properly evaluate the presence of masses, tenderness or enlargement of
the uterus
2. OB PHYSICAL EXAMINATION
 ABDOMINAL PE
 Inspection (Same with Gyne Inspection Assessment)
 Palpation
o Fundic height: uterine size
o Uterine architecture, shape, symmetry, consistency should be notes
o Tone, contractions and Other masses should be noted
o Leopold’s Manuever must be performed
o Fetal movements should be recorded.
 Fundic Height is measured from top of symphysis to top of fundus (in centimeters)
o This fundic height coincides with 18-32 weeks AOG
o Height at umbilicus approximates AOG at 20 weeks
o Fundic height is at its peak at 36 weeks then fundic height deceases.
o Fundic height becomes shorter at 40 weeks AOG due to lightening of the fetus and
decreased amount of amniotic fluid
 Leopold’s maneuver (assesses Lie, Position, Presentation, Engagement)
o Done at 2nd trimester
o Accuracy greatest after 36 wks AOG
o This maneuver is used to assess adequacy of fetal growth and readiness for vaginal birth
o Fetal Lie is in Relation of the long axis of the fetus to that of the mother. It can be:
- Longitudinal: long axis of fetus aligned to the mother
- Transverse: long axis of fetus perpendicular to the mother's: (there is no
presenting part; wide abdomen; fundic height is smaller than expected;
Large parts are palpable laterally with head on one side and breech on the
other; fetal heart beet is at the periumbilical area; or
- Oblique: long axis of fetus 0-90/ 90-180 degrees to that of mother’s
o Fetal Position is in relation of an arbitrarily chosen portion of the fetal presenting part to
the right or left side of the maternal birth canal.
o Fetal Presenetation can be: Cephalic – head, Occiput; if occiput is near the symphysis
pubis then it is ANTERIOR occiput; most common presentation; it can also be Breech
(buttocks or sacrum); Shoulder can also be considered – ACROMION; Face presentation
is when head is hypextended and if slightly extended, it is a Brow presentation.
o Foetal engagement: indicates amount of head above or below pelvic brim: considered
engaged if head is below the pelvic brim and not engaged if head is above the pelvic
brim.
o To perform Leopold’s Maneuver: prepare patient. Mother should be in an examining
table in supine lying position with the knees slightly flexed. The abdomen is exposed. If
examiner is right handed, he should stand at the mother’s Right side facing her for the
first 3 maneuvers, then turn and face her feet for the fourth manoeuvre.
o Leopold’s I: First manoeuvre is the Fundal grip which determines fetal part occupying
the fundus: to perform this manoeuvre, Physician faces the mother and palpates the
 fundus with tips of fingers of both hands to identify the fetal pole. Next is you have to
assess the shape, size, consistency and mobility of fundus. If cephalic in presentation
buttocks is softer, larger, nodular and bony prominences are palpated. If breech
presentation, fetal head is firm, hard and round. It is freely movable and ballotable.
o Leopold’s II: Second manoeuvre is the Umbilical grip. It determines the location of the
fetal back. It is performed by facing the mother and placing both palms on either side of
the abdomen. With a gentle deep palpation, determine the position of the back. Hold
right/left hand still, while the left/right hand palpate for fetal parts. It is fetal back if it is
hard, firm, smooth, and convex (R or L). It is fetal small parts if lumpy, small nodulations
or protrusions can be palpated.
o Leopold’s III: Third manoeuvre is the Pawlick’s grip which is used to determine fetal
parts over pelvic inlet (presentation and engagement).It is done by gently grasping lower
portion of abdomen (just above symphysis pubis) using thumb and fingers of R hand.
Then confirm presenting part by palpating what is opposite of the fundus. If it is firm,
hard and round then it is indicative of cephalic presentation. If it is soft large and
irregular then it is breech. To confirm for engagement: it is not engaged if presenting
part is still movable back and forth. But if it is fixed in the pelvis, then it is engaged.
o Leopold’s IV: Fourth manoeuvre is the Pelvic grip which is used to determine
engagement and presenting part. This is done by Facing mother’s feet and moving three
fingers of both hands with gentle pressure down the sides of abdomen towards pubis. If
finger of one hand descends deeply down the pelvis, while the other hand is arrested
sooner, then fetus is not yet engaged. If fetus is engaged, both hands converge from
each other. Physician must also palpate for the presenting part (cephalic prominence):
vertex if same side as small parts (head flexed) and Face if same side as fetal back (head
extended). To record: L1: Breech or Cephalic presentation, L2: fetal back or fetal small
parts, L3: Engaged or Not Engaged and L4: vertex or face.
 Auscultation: used to determine Fetal Heart Beat (FHB)/ Fetal Heart Rate (FHR) / Fetal Heart
Tones (FHT). Beats recorded normal range is at 110-160 beats/minute. Maternal pulse can also
be noted as slower, sharp, and distinct from FHB. Upon auscultation, uterine souffle or the
passage of blood through dilated uterine vessels can be best heard at the lower portion of the
uterus. Umbilical cord funic can be heard as sharp, whistling sound, synchronous with FHB.
Gurgling of gas in intestines can also be heard.
 OB PELVIC EXAM: used to establish the diagnosis of pregnancy. It is aims to: determine the
presence or absence of uterine or adnexal pathology; evaluate the obstetric pelvis; to check for
cervical status prior to and during labor, check for presenting part of the fetus, and to check for the
status of the bag of water.
 Inspection and palpation of Genitalia: note for lesions, status of perineum whether intact or
lacerated.
 Speculum Inoculation: insert and open the speculum gently to prevent tissue trauma and
bleeding. Sign of pregnancy in vagina and cervix that must be noted is the Chadwick’s sign –
bluish-red passive hyperemia of cervix. Local lesions may also be noted. If vaginal secretions are
recorded, it should be characterized by consistency and odor.
 Internal Examination: Tightness or laxity of introitus, status of cervix (Architecture, shape,
position, consistency, tenderness), Softening of cervix (Goodell’s sign) and thinning of cervix or
effacement maybe note in a patient in IE. Fully effaced cervix at 5cm (paper thin) is indicative
mother is in active labor. Other findings in IE: Fetal parts, position, and presentation and station;
Polyps and other lesions, and landmarks of bony pelvis forming birth canal.
 Bimanual Examination: Hegar’s sign – softening of uterine isthmus indicates the lower uterine
segment during labor. Corpus luteum may be palpable as a small nodule on the affected ovary
during the first weeks after conception.
 RectoVaginal Examination: used to assess perineal membrane and competence of rectal
sphincter. Rectocoele and rectal pathology can also be noted using this examination. Lastly it is
used to assess integrity of rectovaginal septum and in determining the size of a retroverted or
retroflexed uterus.

Reference: Bates’Guide to Physical Examination and History •Taking. 11th ed.