History taking and physical examination in

Gyn-Obs
• Physical Dx = Art of medicine
I. GYNECOLOGICAL PHYSICAL DIAGNOSIS
 Timing of gynecological assessment
1. GYNECOLOGICAL HISTORY------Components
A. IDENTIFICATION
 AGE------- Women life cycle
 Prepubertal
 Adolescence
 Reproductive age group
 Perimenopausal
 Postmenopausal
 Address
 Marital status
 Occupation
A. Chief complaints-----4 common complaints
B. History of present illness-------TPAL
 Summary of past reproductive performance
 Term deliveries
 Preterm births
 Abortions
 Living children
 Common complaints-----elaborate in detail
 Vaginal discharge
• Color, odor, amount
• Pruritis
• Timing in relation to menstrual cycle
• Association with abnormal Vx bleeding—malignancy
 Vaginal bleeding---AUB
• Time of onset
• Flow---amount, duration, relation with menstrual cycle &
  Pain ------PQRST
• Location (Position)
• Quality
• Radiation
• Severity
• Timing----intermittent, constant etc; relationship to menstrual
cycle
 Abdominal swelling, urinary complaints
 Inability to conceive
D. Menstrual history--- 13/4/28,moderate,painless
 Menarche---age of onset
 Regularity of the cycle
 Duration of period
 Length of the cycle
 Amount of bleeding----number of pads, clotting
 LMP
 Pain
  Abnormal menstrual cycles:
 Menorrhagia– regular cycle, heavy flow >80ml
 Metrorrhagia--- irregular cycle
 Menometrorrhagia --- irregular cycle, excessive in amount
 Metrotaxis---- continuous uterine bleeding
 Hypomenorrhea---normal cycle, shorter duration of flow
 Polymenorrhea---frequent cycles (<21 days of cycle length)
 Oligomenorrhia----cycle length >35 days
D. Gynecologic history---STD, PID, Fertility regulation,
procedures, surgery, sexual history
E. Obstetrical history
F. Past medical and surgical history
G. Personal and social history----education, substance abuse,
SES
H. Family history---complaints that may run in family--- breast &
gynecological diseases
I. Review of systems
2. Physical examination---complete evaluation, Chaperone
A. General physical examination
B. Vital signs, weight, height, BMI
C. Breast examination
D. Abdominal examination---empty bladder, abdominal Vs pelvic masses
and their differentials and description
• Inspection
• Palpation---- superficial and deep palpation
• Percussion
• Auscultation
E. Pelvic examination
 Materials
• Table with stirrups
• Light source
• Speculum
• Slides, cotton tipped applicators
• Lubricant, disposable gloves
 Components--- 4
 1. Examination of external genitalia
 Inspection
 Palpation
2. Speculum examination
 Types ---Sim’s, Cuscos (Graves), Pederson’s, Huffman’s
 Size
 Damped with warm water (not lubricants)
 Examination ---explain findings of inspection
3. Digital vaginal examination– vagina, cervix, fornices
4. Bimanual pelvic examination
 Cervix, uterus, adnexae, pouch----note the findings
 Rectal examination—rectal mucosa, parametrium, virgin
 Rectovaginal examination—GI pathology
 Examination under general anesthesia (EUA)
3. Laboratory and diagnostic tests
II. OBSTETRIC PHYSICAL DIAGNOSIS
 Timing and objectives
 Preconception care
 ANC
 RISK ASSESSMENT
1. HISTORY
A. Identification
B. Chief complaint
C. HPP
 Gravidity
 Parity
 GA, fetal kick
 ANC events +/- Statements
 Past obstetric history Gyn-Hx.
 Past medical & surgical history
 Personal history
 Family history
2. Physical examination
A. General appearance
B. Vital signs---physiologic changes, weight, height, BMI
C. Examination of other systems---CVS, chest
D. Abdominal examination—
 Inspection----- obesity , scars, striae, pigmentation
 Palpation
 Percussion—shifting dullness—ascites, polyhydramnions
E. Obstetric abdominal examination (Leopold’s maneuvers—4)
1. Fundal palpation---fundal height, what occupies fundus
2. Lateral palpation---Lie, side of the back
3. Pelvic palpation—Presentation, Descent of presenting part,
Attitude of the fetal head
4. Pawlik’s grip—Presentation, Descent of fetal head
 Auscultation--FHB
F. Pelvic examination----done 2X during pregnancy unless indicated
1. Early---first trimester
 To diagnose pregnancy
 To date pregnancy
 To diagnose pelvic problems/ pathology
2. Late in pregnancy (38 weeks or at term) --to Dx contracted pelvis
 Soft tissue assessment
 Bony pelvis assessment
 Pelvic inlet-----Diagonal conjugate
---- Head fitting test ( Mueller-Hilton’s maneuver)
 Mid cavity---ischial spine, sacrospinous ligament, concavity of sacrum
 Outlet subpubicarch
 To asses the Bishop’s score---cervical status
G. GUS----CVA(costovertebral angle ) or suprapubic tenderness
H. Extremities, Neurological ---edema, deformities, varicosity, DTR etc
I. Investigations during pregnancy—Maternal, Fetal

 RISK SCORING OF PREGNANCY