HISTORY & PHYSICAL EXAM

IN OB/GYN

By: - Dr Amanu
What is Obstetrics?
The word obstetrics is derived from the Latin obstetrix,
meaning midwife.

The word also is connected with the verb obstare—to

stand by or in front of.

The rationale for this derivation is that the midwife

stood by or in front of the parturient.
HISTORY & PHYSICAL EXAM IN
OB/GYN
COMPONENTS OF OBSTETRIC HISTORY:
 Identification
 Chief complaint (C/C)
 Hx of present pregnancy (HPP)
 Past Obstetric Hx
 Past Gynecologic Hx
 Past Medical & Surgical Hx
 Personal & Social
 Family Hx
 Systemic Review
 COMPONENTS OF OBSTETRIC P/E
 General Appearance (GA)
 Vital Sign (V/S)
 HEENT
 Lympho- glandular system (LGS)
 Respiratory System (RS)
 Cardiovascular system (CVS)
 ABDOMEN (GIT)
 Genito – Urinary System (GUS)
 Integumantary System
 Musculoskeletal System (MSS)
 Nervous System (NS)
 SUMMARY OF Hx & P/E
 ASSESSMENT/ or DIAGNOSIS /or IMPRESSION
 DIFFERENTIAL DIAGNOSIS (DDx)
 INVESTIGATIONS
 TREATMENT PLAN
OBSTETRIC HISTORY
 
1. IDENTIFICATION: - Emphasize on
- Name
- Age: <18 yrs or > 35 yrs = > high risk group.
- Marital status:
=> Unmarried & unsupported are high risk group.
- Address, Religion, Ethnicity
- Date of admission, Ward, bed number
- Occupation
- Previous history of admission,
- How the patient was brought to the hospital
- Source of information, language of communication
- Source of referral
 2. CHIEF COMPLAINT (c/c):

- Patients might have come for scheduled ANC follow up or

- May have a specific complaint e.g. nausea and Vomiting,
Vaginal bleeding etc.
 
3. HISTORY OF PRESENT PREGNANCY (HPP):
It should include the following information:
Gravidity – all previous pregnancies
– Term live birth, still births, abortions, ectopic
pregnancy or hydatidiform mole.
Parity – Pregnancies that have extended beyond fetal viability
whether the fetus is delivered alive or dead.
> 28 weeks: - UK and Ethiopia
> 20 weeks for WHO
Abortion(s); number, induced or spontaneous
 HPP…
LNMP: - 1st day of normal period. To be considered as reliable if:
- Menstrual cycle has been regular
- No use of hormonal contraceptives for at least 3 months prior
to LNMP or regular cycles
- If lactating, should have seen at least 3 regular cycles
Calculate the EDD: – 40 weeks or 280 days after LMP
– 5% of pregnant women deliver on this day.
Term pregnancy: 37 – 42 completed weeks.
Preterm pregnancy: < 37 completed weeks.
Post term pregnancy: > 42 ›› ››
Naegle’s rule: LNMP – 3 months + 7 days (for the European C.).
For the Ethiopian calendar:
EDD = LNMP + 9 months + 10 days if Pagume is not crossed, or
EDD = LNMP – 3months + (5 or 4 days if Pagume is 5 or 6 days
respectively), If Pagume is passed or crossed.
Calculate gestational age in completed weeks and days.
 HPP…
Quickening: - 1st time the mother felt fetal movement or kick
- used to calculate the date of the pregnancy if LMP is
unknown.
= > for Primigravidas: b/n 18 – 20 weeks.
= > for Multigravidas: b/n 16 – 18 weeks.
ANC status should be documented & if not followed, the reason should be
sought.
Elaborate the chief complaint
Any complaints during the present pregnancy- eventful or uneventful
Ask for danger signs: - Vaginal bleeding, leakage of liquor, abdominal
pain, fever, … etc.
Fetal movements decreased or increased? It is useful to assess fetal well
being.
Other negative and positive statements should be asked according to the
patient’s complaints e.g.
Headache, blurring of vision, epigastric pain or convulsion in hypertensive
disorders of pregnancy etc
4. PAST OBSTETRIC HISTORY…

=> Document all previous pregnancies in a chronological

order.
Year of gestation, Length of gestation, birth weight, fetal
outcome, length of labor, fetal presentation, mode of
delivery,

Complications: - Ante partum, intrapartum & post

partum.

Important because most obstetric problems are recurrent

and have a chance of recurring in the current pregnancy
e.g. APH, PPH, PROM, GDM, PIH, C/S, Ectopic
pregnancy & abortion.
 PAST OBSTETRIC Hx, Summary
Order of Antepar Length of Length Mode of Birth Postpart Child
pregnan tum Gestation of labor Delivery Outcome um alive
cy complic complica or not
ations tion

1st

2nd
5. PAST GYNECOLOGIC HISTORY
- Contraception – use of any form of contraception, type
and duration
 Sexual history – including history of STD: Assess risk of
HIV / AIDS
 History of gynecologic procedures including history of
female genital cutting (FGM).
 History of previous gynecologic surgery or procedure
– e.g. prior uterine surgery; hysterectomy, myomectomy,
D&C, MVA, E&C…
 Menstrual history: age at menarche, interval between
periods, duration of flow, amount and character of flow,
degree of discomfort.
 PAST GYNECOLOGIC HISTORY…
Normal menstrual cycles:

= > 1 – 8 days of flow / 5 days on average

= > 21– 35 days cycle length / 28 days on
average.
= > 10 – 80ml /50ml on average amount of
blood flow              
     = > Dark non- clotting blood.

Clotting of menstrual blood, increased number of pads

used and anemia indicate pathology.
6. PAST MEDICAL AND SURGICAL Hx:
Medical disorders may affect the outcome of pregnancy
and the physiological changes of pregnancy may
aggravate the medical disorder. e.g. Diabetes mellitus,
Hypertension, Thyrotoxicosis or Hypothyroidism, Tb, etc
Previous blood transfusion – may be related to hemolytic
disease of the newborn.
Hypersensitivity to drugs should be asked.
History of maternal infection during pregnancy should be
asked – e.g. STD, rubella, malaria, etc.
 Previous hx of surgery: eg, appendectomy,
cholecystectomy, thyroidectomy ….etc
7. PERSONAL & SOCIAL HISTORY (+ FAMILY HISTORY)
Early childhood history, number of siblings, whether
parents and siblings are alive or not. If dead, reason for
death should be mentioned to uncover familial reasons.
Educational status
Habits – smoking, alcohol and drug use may have a
deleterious effect on pregnancy.
e.g. fetal alcohol syndrome.
Occupation and family income – Low socio economic
status is associated with pregnancy complication. e.g.
pre-eclampsia, preterm labor, PROM, etc.
 8. FAMILY HISTORY

Family history of – Diabetes mellitus, Hypertension,

Tuberculosis, Twinning, Hereditary diseases,
chromosomal anomalies, allergies, and mental
disorders- running in the family.
 
9. SYSTEMIC REVIEW / FUNCTIONAL ENQUIRY

 A check list for the health professional in all the

systems
HEENT
Head: Headache, head injury, dizziness,
lightheadedness.
Eyes: Vision, glasses or contact lenses, last
examination, pain, redness, excessive tearing, double
vision, blurred vision, flashing lights
Ears: Hearing loss, tinnitus, vertigo, earaches,
discharge.
Nose and sinuses: Frequent colds, nasal stuffiness,
discharge, or itching, hay fever, nosebleeds
Throat
 (or mouth and pharynx):Condition of
teeth, gums, bleeding gums, sore tongue, dry
mouth, frequent sore throats, hoarseness.
Lymphogladular system: neck swelling, lump
in the neck, lump in the breast, breast pain or
discomfort, nipple discharge, any groin/axillary
swelling noticed by patient
Respiratory: Cough, sputum (color, quantity),
hemoptysis, dyspnea,wheezing, pleurisy
Cardiovascular system: chest pain or
discomfort, palpitations, dyspnea, orthopnea,
paroxysmal nocturnal dyspnea, edema,
intermittent claudication
Gastrointestinal system: trouble swallowing,
heartburn, appetite, nausea, color and size of stools,
change in bowel habits, rectal bleeding or black or
tarry stools, hemorrhoids, abdominal/right upper
quadrant pain, food intolerance, excessive belching or
passing of gas.
Genitourinary system: Frequency of urination,
polyuria, nocturia, urgency, burning or pain on
urination, hematuria, flank pain, urethral/vaginal
discharge or other symptoms of sexually transmitted
disease
Musculoskeletal system: muscle or joint pains,
redness, stiffness, presence of any swelling,
weakness, or limitation of motion or activity;
include timing of symptoms (for example,
morning or evening), duration, location and
any history of trauma.
Integumentary system-rashes, sores, itching,
dryness, color change, changes in hair or
nails.
Neurologic system: Fainting, seizures,
weakness, paralysis, numbness or loss of
sensation, tingling or “pins and needles,”
tremors or other involuntary movements.
B. PHYSICAL EXAMINATION (P/E)
P/E should be conducted in an environment that is
aesthetically pleasing to the patient. A female assistant
(chaperone) should be present whenever possible.
Adequate gowning and draping is necessary to avoid
embarrassment. Warm instruments, reassurance and
adequate lighting should be used.
 
General physical examination covering all the systems
should be conducted thoroughly.
1. GENERAL APPEARANCE:
- Acutely or chronically sick looking, well looking,
- Mood of the patient,
- Body morphism (nutritional status)
 P/E…
2. VITAL SIGNS:
Blood pressure: – should be measured in the sitting position
or 30 degree left lateral tilt to avoid supine hypotension
syndrome due to vena caval compression. DBP is taken at
the point of disappearance (5th Korotkoff’s) point.
Pulse: 10 – 15 beats / minute increase in pulse rate during
pregnancy.
RR: 1 – 4 breathes / minute increase during pregnancy
Temperature
Weight: - ideal body weight found by using Broca’s formula
= Height in cms – 100
 +/- 20% this is the cut off point for the normal range.
 Weight gain > 1Kg / wk is abnormal
Height < 150 cms is a risk for contracted pelvis (CPD)
3. HEENT EXAMINATION

-Emphasize on head, ear, eye (conjunctiva, sclera), nose

and throat or teeth
 
4. LYMPHO-GLANDULAR SYSTEM (LGS):
- All superficial lymphatic system should be evaluated.
- Glands:- Thyroid
- Breast:- detailed examination
- Nipple retraction:– should be treated during
pregnancy so that it will not interfere with breast
feeding.

5. RESPIRATORY SYSTEM / Chest – same as non-

pregnant.
6. CARDIO-VASCULAR SYSTEM
Same as non – pregnant

- PMI may be deviated to the left.

- S3 gallop may be heard normally.
- Functional systolic murmur < III/VI grade may be
heard.
a) Inspection:
7. ABDOMEN

 Distension – site of distension, uniformity, shape and

peristalytic movement
 Symmetry: symmetrical or asymmetrical - tilted to the right
or to the left
 Linea nigra- midline hyperpigmentaion due to increased
Melanocyte Stimulating Hormone (MSH) during pregnancy
 Stria gravidarum – purplish mark on the abdomen, thighs
& breasts due to the distension.

 New Stria gravidarum are few in number, thick and

purplish to dark in color.
 Old Stria gravidarum (Stria albicantes) are whitish, much
thinner and numerous in numbers compared to the new ones.
 7. ABDOMEN…
Inspection…
 Umbilicus - flat, inverted or everted.
 Scars: - surgical or non- surgical
 Surgical:
- sub umbilical midline or
- Pfannensteil - suprapubic transverse scar
 Distended veins
 Flanks – full or not
 Pulsatile mass
7. ABDOMEN…
b. Palpation:
i. Superficial palpation-
Look for rigidity, tenderness, superficial mass,
characterizes mass, abdominal wall defect.
ii. Deep Palpation
Look for mass, organomegally, tenderness
Characterize mass (size, organ, mobility, tenderness,
shape, and contour)
iii. Obstetric palpation:
Leopold I: – Fundal palpation.
- Has 2 purposes:
1) Determination of fundal height, and
2) What occupies the fundus?
 OBSTETRIC PALPATION…
Leopold I: – Fundal palpation…

Fundal height (fh) measurement - should be after

correcting for dextrorotation.
There are 2 methods of measuring the fh:
1. Finger method:
- below the umbilicus, 1 finger = 1 week
- Above the umbilicus, 1 finger = 2 weeks
OBSTETRIC PALPATION…
Body marks:
- Uterus at symphysis pubis = 12 weeks
- At the umbilicus = 20 weeks
- At Xiphisternum = 38 weeks
- Midways b/n symphysis & umbilicus = 16wks
- Midways b/n umbilicus & Xiphisternum
= 28wks
OBSTETRIC PALPATION…
2. Tape measurement:
 Symphysis to fundal height measurement in cms with
tape meter.
 At 18 – 34 wks of gestation, tape measurement is
accurate to +2 weeks of actual GA.
 McDonald rule & Johnson formula for GA & Fetal
weight estimation.

 What occupies the fundus?

 Soft, irregular, bulky mass - the breech
 Hard, round, ballotable mass – Head
 OBSTETRIC PALPATION…
Leopold II: – Lateral palpation
Has 2 purposes: 1) To know the lie
2) To determine side of the back
1. Lie:
 is the longitudinal axis of the fetus in relation to the
longitudinal axis of the mother.
 It can be longitudinal, transverse or oblique.
2. Side of the back – to auscultate the FHR on that side.
 FHR can be auscultated
at 20 wks by using the De Lee /Pinard stethoscope or
at 10 - 12 wks using Doppler Ultrasound.
 OBSTETRIC PALPATION…
Leopold III – pelvic palpation
– It has three purposes; to know the
1) Presentation
2) Descent of presenting part.
3) Attitude of the fetal head.
 Presentation: – is the part of the fetus that occupies
the lower uterine pole.
E.g. Cephalic, breech(back) & shoulder presentation

Descent is measured after identifying the anterior

shoulder with rule of 5th in fingers above pelvic brim.
5/ 5th – floating 4/5th-fixed
2/5th – engaged at the pelvic inlet.
OBSTETRIC PALPATION…
Attitude: is the relationship of the fetal parts to each
other particularly the fetal head to its trunk.
- Cephalic prominence on the side of the back.
Extended attitude = > abnormal
 Cephalic prominence opposite to the side of the back
 Flexed attitude = > normal
 Military Attitude: - neither flexed nor extended

 Leopold IV – Pawlik’s grip: – It has two purposes.

To know the 1) Presentation and
2) Descent or mobility of the fetal head
=> floating or fixed
7. ABDOMEN…
c. Percussion: – Shifting & flank dullness and fluid thrill –
as in ascites & polyhydramnios

d. Auscultation: - FHB first heard at the 20th week – On

the side of the back.

 Below the umbilicus in cephalic presentation

Above the umbilicus in breech presentation
 At flanks in OP position
  Pelvic assessment (P Exam):
8. GENITOURINARY SYSTEM


Speculum and digital examination refer to gynecology

section.
Done at two times during pregnancy unless otherwise
indicated due to complications and in labor
1. Early – During the 1st trimester as early as possible.
Purposes: -
To diagnose pregnancy
To date pregnancy by measuring uterine size
To diagnose pelvic problems like ovarian cyst and uterine
anomalies & Vaginal congenital anomalies like septum as
early as possible.
 GENITOURINARY SYSTEM…
2. Late in pregnancy (>37 Weeks).
Purposes: - for soft tissues assessment
For pelvic assessment to diagnose contracted pelvis/ bony
pelvis assessment          
= > to assess the pelvic inlet, mid cavity & outlet.

Inlet:
- Diagonal conjugate - 1.5cms = true conjugate
- AP diameter or is the sacral promontory reachable or
not?
 GENITOURINARY SYSTEM…
Mid cavity:
- Assess prominence of ischial spines,
- Sacrospinous ligaments should accommodate 3 fingers
- Concavity of the sacrum – concave normally.
- Pelvic sidewalls: - Straight, convergent or divergent.

 Outlet:
- Sub pubic arch should accommodate 2 fingers,
- The intertuberous diameter should
accommodate the four knuckles of a clenched fist
- The coccyx (sacrococcygeal joint) must be mobile. 
 GENITOURINARY SYSTEM…
- To assess the Bishops score:
=> the status of cervical ripening for induction.
= > 5 factors assessed: - Cervical effacement, dilatation,
softening, position, and station.

3. In Labor:
- To evaluate the cervical dilatation, effacement & station of the
presenting part.

- Ascertain presentation, position, moulding, and caput

formation and evaluate the pelvis. 

b. GUS - CVA tenderness or suprapubic tenderness.

9. INTEGUMANTARY SYSTEM…
INTEGUMANTARY SYSTEM : - as in Gynecologic
history

10. MUSCULOSKELETAL SYSTEM:

 Extremities - Look for edema – pretibial, ankle & pedal
(dependent edema)
= > 80% of normal pregnant women can have dependent leg
edema.

Other areas to look for pathological (Non-dependent edema.)

= > Facial edema.
= > Tightening of rings (finger)
= > Sacral edema
= > Abdominal wall edema
 11. NERVOUS SYSTEM (NS):
Nervous System: - see Gynecologic P/E part
- Reflex
Reflexes are usually graded on a 0 to 4+ scale:
4+ Very brisk, hyperactive, with clonus (rhythmic oscillations between flexion
and extension)
3+ Brisker than average; possibly but not necessarily indicative of disease
2+ Average; normal
1+ Somewhat diminished; low normal
0 No response

- Consciousness
- Gross neurological deficit
 

12. Summary of Hx & P/E

13. Assessment Or Diagnosis Or Impression
14. Differential Diagnosis (DDx)
15. Investigations
16. Treatment plan
INTRODUCTION TO GYNECOLOGY
What is Gynecology?

Gynecology, spelled gynaecology, is defined by the

Oxford English Dictionary as a department of medical
science which treats of the functions and diseases
peculiar to women.

The word was first used as such in the middle of the

19th century. In 1867, gynecology represented the
physiology and pathology of the non pregnant state.
GYNECOLOGIC Hx & P/E
COMPONENTS OF GYNECOLOGIC HISTORY:
 Identification
 Chief complaint (C/C)
 Hx of present illness (HPI)
 Past Gynecologic Hx
 Past Obstetric Hx
 Past Medical & Surgical Hx
 Personal & Social
 Family Hx
 Systemic Review
 GYNECOLOGIC HISTORY
IDENTIFICATION: - same as obstetric history
CHIEF COMPLAINT(S): - same as obstetric history
Gynecologic patients may present with any one of the following
complaints:
E.g. - Cessation of menses.
- Vaginal bleeding
- Vaginal discharge
- Lower abdominal pain
- Pain during menstruation
- Mass protruding out of the introitus
(mass per vaginum)
- Urinary incontinence
- Ulcers on external genitalia
- Abdominal distension
- Hirsutism – abnormal hair growth pattern
 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
 HISTORY OF PRESENT ILLNESS (HPI)

Reproductive history: Parity, Abortions, Ectopic

pregnancy
Each complaint should be discussed in detail.
Each problem – where exactly is it occurring?
Date and time of onset
Aggravating or relieving factors
Duration when they occur, Example,
Abnormal uterine bleeding (AUB): - Describe clearly
onset, duration of flow, amount- indicated by number of
pads used per day, clotting of menstrual blood. Describe
relation of AUB to menstrual cycle & LNMP.
LNMP should be included in the HPI. Menstrual history in
detail can be included in the HPI or elsewhere if not
pertinent to the present complaints.
 HPI…
Vaginal discharge:
- Color, odor, amount, Viscosity.
- Timing in relation to menstrual cycle
- Associated with abnormal vaginal bleeding- may indicate
malignancy
- Itching – indicates infection
Abdominal pain: – PQRST
- Location (position)
- Quality
- Radiation
- Severity
- Timing - intermittent, constant, etc
- Especially relationship to menstrual cycle
- Pain during menstruation could be primary or secondary
dysmenorrhea.
 HPI…
Contraceptive history, sexual history and menstrual
history should be included in the HPI if pertinent to the
present complaints other wise can be included in the past
gynecologic history.

Negative – positive statements pertinent to the presenting

complaints should be discussed in detail.
 
Menstrual history: - Age at menarche, interval between
periods, duration of flow, amount and character of flow,
degree of discomfort and age at menopause.
 HPI…

PAST GYNECOLOGIC HISTORY: - As in obstetrics history

 
PAST OBSTETRIC HISTORY: - As in obstetrics history
 
PAST MEDICAL AND SURGICAL HISTORY: - As in
obstetrics history
 
PERSONAL & SOCIAL HISTORY: - As in obstetrics history
 
FAMILY HISTORY: - As in obstetric history
 
 SYSTEMIC REVIEW / FUNCTIONAL ENQUIRY:
GYNECOLOGIC PHYSICAL EXAMINATION

A. GENERAL APPEARANCE: - as in obstetrics

B. VITAL SIGNS: - as is done for any patient

 Weight: – obesity is a risk factor for certain gynecologic

illnesses: e.g. Endometrial Ca, Ovarian Ca, Amenorrhea.
 Height: – especially important in postmenopausal
patients to document loss of height from osteoporosis and
vertebral fractures.
C. HEENT: - as in obstetrics
 D. LYMPHOGLANDULAR SYSTEM:

Breast examination:

Inspection: - with patient’s hands pressing on her hips and

arms above the head respectively
- Symmetry, dimpling, peau-de- orange, nipple retraction,
ulceration & eczematous nipple lesions should be
documented

Palpation: – all four quadrants, axillary’s tail, nipples area

for discharge.
- Axillary, supraclavicular and cervical lymph nodes should
be palpated with detailed description of a mass.
GYN P/E…
E. RS: - as in any other patient

F. CVS: - as in any other patient

G. ABDOMINAL EXAMINATION

- Inspection: – as usual as is done for any patient.
- Auscultation: - Bruit over a mass & bowel sound
- Palpation: - Superficial
- Deep
ABDOMINAL EXAMINATION…

 Abdominal Mass: – Describe Size, origin, consistency,

mobility, tenderness and contour
 Size: - in weeks of pregnant uterus size
- 12 weeks at symphysis pubis
- 20 weeks at umbilicus
- 38 weeks at xiphisternum
 Origin: - pelvic - abdominal mass arising from the
pelvis or an abdomen can be differentiated by identifying
if one can go below the mass in to the pelvic cavity or
not?
 Consistency: - firm, hard, soft or cystic.
 ABDOMINAL EXAMINATION…

 Mobility: - fixation may indicate adhesions or

malignancy
 Tenderness
 Surface contour: - smooth, irregular or nodular
Check for Organomegally: – liver, spleen, Kidneys.
 
Percussion: - Shifting dullness, fluid thrill to detect ascites
Differentiation of a large ovarian tumor versus ascites: -
Large ovarian tumor has central dullness with
tympanicity at the flanks as opposed to ascites with
central tympanicity and peripheral dullness.
H. GENITOURINARY SYSTEM:

= > CVA and suprapubic tenderness

= > Pelvic Examination

Pelvic examination: – has 5 components

1. - Examination of external genitalia
2. - Speculum examination
3. - Digital vaginal examination
4. - Bimanual pelvic examination and
5. - Recto vaginal examination
 Pelvic Examination…
A. Examination of external genitalia: - Inspection and
palpation
- Pubic hair pattern: - Masculine-diamond shaped
- Feminine-inverted triangle.
- Infected hair follicles etc.
 Skin of vulva, mons pubis and perineal area inspected for
dermatitis or discoloration
e.g. whitish discoloration in vulvar dystrophies.
 Ulcers or swelling E.g. sebaceous cysts or tumors
 Labia majora and minora:
 Ulcers, swelling or tumors such as Condyloma accuminata
could be found.
 Evidence of FGM - scarring etc.
Pelvic Examination…
Urethral orifice: - should be of the same color as
surrounding
- Milk for discharge
- Urethral caruncle or tumor if any
 Area of Bartholin’s gland: - at 5 & 7 o’clock position
- Inspection & palpation for swelling and tenderness
Discharge or bleeding from the introitus – should be
noted.
 Pelvic Examination…
Hymen: - Unruptured, many forms – annular, crescentic,
or fimbriated.
- Imperforated hymen is pathological
- Ruptured - especially after the birth of many children
                                               
 - remnants of ruptured hymen is called carunculae
myrtiformis.
- Examination of hymen is important in cases of sexual
assault.
- Check perineal support: – open the labia with 2 fingers
and ask patient to strain to document
genital prolapse.
 Pelvic Examination…
B. Speculum examination
- Speculum – Dampened with warm water but not
lubricants
- Types: - Cusco’s (Graves): bivalve speculum.
- Sims speculum: mono valve speculum
- Choice of several sizes depending on age etc.
 The following should be documented.
Vagina: - Color- pink, whitened, inflamed
- Congenital anomalies like vaginal septum.
- Fornices: - formed, flattened, bulging
especially posterior fornix
- Discharge: - color, amount
- Scars, lacerations
 Pelvic Examination…
Cervix: - Os: – Nulli parous – pinpointed.
- Multiparious – slit-like
- Erosions, scars, lacerations, ulcer, mass,
- Nabothian cysts, discharge or bleeding
- Effacement, dilatation,
- Any mass or polyp from Os or from the surface

Papanicoulau’s (Pap) smear should be taken at this time

from the exocervix and endocervix using
Ayre’s spatula and an endocervical brush respectively.
SPECULUM
Pelvic Examination…
C. Digital vaginal examination: - Note the following
The patient should have voided just prior to examination to
avoid difficulty in examining the uterus and adnexa by the
distended bladder.

Vaginal: - masses, tenderness or stenosis

Fornices: - formed or obliterated
- Bulging especially posterior fornix (cul-de-sac)
- Tenderness

Cervix: – consistency: – Tip of nose – normal

- Hard in malignancies.
- Excitation (motion) tenderness
- Effacement, position & dilation
 Pelvic Examination…
D. Bimanual pelvic examination:

- To delineate the uterus and adnexa between the 2 fingers in

the vagina and the palm of the other hand on the lower
abdominal wall.
- EUA may be required in obese patients

- Note the following:

a. Cervix: - 3- 4 cms in diameter, round, tip of the nose
consistency
- External os is usually closed
- Smooth surface normally
- Can be moved 2- 4 cms in any direction without discomfort.
 Pelvic Examination…
b. Uterus: - Dimensions of normal uterus = 9 cms in length,
7 cms in width, 70 - 90 grams in weight.
 Assess the following regarding the uterus:

 Position: – Anteverted – normally

- Ante flexed – body of the uterus flexed at cervix
- Retroverted & retroflexed normally in 20% of cases
 Tenderness: – normally non- tender organ
 Pelvic Examination…
b. Uterus…

Mobility: – mobile in all directions normally.

Fixation: – may be due to cancer / neoplasia or
inflammation.
Size: – described in pregnant uterus size; in weeks
 Surface contour: - smooth normally
Consistency: – firm normally
 Pelvic Examination…
c. Adnexa: - Refers to the –Tubes, ovaries, broad ligament
and parametrium

Ovaries: - 3cm x2cm x l cms in size.

= > May be palpable in thin women with
soft abdominal walls.
= > Tender normally.
 Tubes diameter = 7 mms at its greatest diameter
Description of adnexal mass: in a similar way to uterine
mass
Bimanual pelivc examination
 Pelvic Examination…
E. Recto vaginal examination:
 It is performed with the index finger in the vagina and
the middle finger in the rectum.

The structures that lie in between the two fingers include

the rectovaginal septum or structures that may dissect it.
A cul-de-sac abscess may dissect the septum and be
detected on rectovaginal exam.
A cervical carcinoma may also infiltrate the septum.
Rectovaginal exam is also useful in differentiating a
rectocele from an enterocele. An enterocele is felt
descending in between the two fingers on straining.
Recto-vaginal Examination
 I.INTEGUMANTARY SYSTEM:

 The skin is examined for texture, dryness or moisture,

temperature, purpura, rashes, urticaria, ulcers and hypo or
hyperpigmentations.
The hair is examined for sparseness, baldness, alopecia
and texture.
The color, shape (clubbing, spooning), texture, capillary
refill and presence of splinter hemorrhages are noted on
examining the nails.
Presence or absence of Hirsutism and its extent is noted.
 J. MUSKULOSKELETAL SYSTEM:

 Presence of muscle tenderness or spasm is noted.

The spine is examined for tenderness on percussion or
pressure, kyphosis, scoliosis, lordosis, malformation,
gibbus and limitation of movement.
Joints are evaluated for swelling, tenderness, redness,
heat, crepitus, limitation of movement on active or
passive motions, effusion, masses, dislocation and
deformity.
On the examination of bones mention is made of
fractures, deformity, tumor, periosteal thickening and
tenderness.
 K. NERVOUS SYSTEM:

 It includes assessment of:

- Central as well as peripheral nervous system functions.
 Mental status: - orientation to time, place & person.
- The 12 cranial nerves for their specific functions
CRANIAL N/S
The 12 pairs of nerves that arise directly from the
brain and leave the skull through separate
apertures; they are conventionally given Roman
numbers, as follows
 CRANIAL N/S
Number Nerve

I olfactory nerve

II optic

III oculomotor

IV trochlear nerve

V trigeminal nerve
CRANIAL N/S
VI abducens nerve

VII facial nerve

VIII vestibulocochlear nerve

IX glossopharyngeal nerve

X vagus nerve
XI accessory nerve
XII hypoglossal nerve
 NERVOUS SYSTEM…
Motor functions (muscle volume, tone, power,
fasciculation & involuntary movements).
Sensory functions:
- Superficial: - light touch, pain, and temperature.
- Deep: - position, deep pain, vibration, Romberg’s sign
& ataxia gait.
Superficial and Deep tendon reflexes:
- Superficial: - includes corneal, abdominal, cremasteric
and plantar reflexes.
- Deep: - biceps, triceps, supinators, patellar and ankle
reflexes.
Meningeal signs (nuchal rigidity, Kerning’s sign and
Brudzinski’s sign).
L. Summary of Hx & P/E

M. Assessment / Diagnosis
N. Differential diagnosis
O. Investigations
P. Treatment plan

……………………….. The End !