Obstetrics and Gynecological History and

Physical examination

Chao Gu M.D., Ph.D.

Dept of Ob/Gyn

OB/GYN Hospital, Fudan University

Medical history collecting and writing (30 min)

Pelvic examination (15 min)

Test (30 min)

Good communication is necessary for the assessment of patient's condition and treatment

communication technique

• concentration• Knowledge• Kindness• Humor?

Trust

• General Item

• Chief Complaint

• Present Medical History

• Past Medical History

• Menstruation History

• Marriage History

• Social History

• Family History

Gynecologic History

• General exam

• Abdominal exam

• Pelvic exam-- Gynecology examination

Gynecologic Physical Examination

Assistant Checkup

• Ordinary test

• Special test

Physical Examination

• Symptoms

• General check up

• Abdomen examination

• Pelvic examination –Gynecology exam

Name, Gender, age, nationality, marriage, occupation, hometown

Address, time of hospitalization, history collecting time, history provider

General Item

The main symptoms or The duration of symptoms （ Professio

nal term, in 20 words)

•12 weeks menopause, vaginal bleeding for two days, abdominal pain for

one hour

•Uterine fibroids found for one month in Gynecological checkup

•G2P0 pregnancy 37 +6 weeks, bloody show for 3 hours

Chief Complaint

• Chronology of chief complaint from when the patient first

felt well until the present

• Detailed description of the chief complaint

--occur, evolution, diagnosis and treatment

procedures

History of Present Illness

Pain

•Location

•Timing (onset, duration and frequency)

•Quality (characteristics)

•Quantity or Severity

•Setting

•Alleviating or Precipitating factors

History of Present Illness

Bleeding

•Onset and Duration

•Constant or Intermittent

•Character

•Intensity

Vaginal Discharge

•Duration

•Characteristics

•Associated Symptoms

•Temporally Related Events

History of Present Illness

Past Medical History

• Medical illnesses (childhood and adult)

• Immunizations

• Surgical history

• Infectious diseases history

• Medications

• Allergies

• blood transfusion history

• Age of menarche, menstrual cycle,volume, associated

symptoms, LMP/PMP, amenorrhea, menopausal age date

• LMP ： Last menstrual period

• PMP ： Previous menstrual period

The female patient, 27 years old, complaint in August menstruation was late, and previous menstrual date was on July 16th. Menarche occurred in junior high, normally 2 days ahead of each period, much volume in first 2 days, less after, accompanied by mild back pain.

Menstruation History

125

2850

• marriage history (times of marriage, age of marriage)

• health condition for husband• history of giving birth:

Full-term-Premature birth-Abortion-Survival

2-0-1-2

• G2P1:pregnancy 2, birth 1

• birth control mesures

Marriage History

Birth place, previous location

bad habits for cigarette and alcohol

Personal Information History

Parents

cousins ， sibling

children

Health conditions

Family History

• Any inheritable disorders

• Special attention to breast, ovarian and colon cancer

• Osteoporosis, heart disease and menopause

Past obstetric history

• Outcome of previous pregnancies in details including the abortions

• Any significant antenatal, intrapartum or postpartum events

• Previous maternal complications

• Mode of delivery

• Baby weight

• Life & Health of the baby

Obstetric History

Abdominal exam

• Inspection

• Palpation

• Ascultation

• Percussion

1 Please write a complaint according to the following information:

• Female patient, 42 years old, complaint in recent 1 years by the increased amount of menses, accompanying a backache with fatigue

• Female patient, 35 years old, lower abdominal pain for 2 days recent one month, and leucorrhea has peculiar smell

Discussion

2 Please according to the following data to write present medical

condition, to see what is needed for history collection:

• At the age of 28, amenorrhea for 2 months,

irregular vaginal bleeding

• 40 years old, the vulva pruritus, leucorrhea is abnormal

• At the age of 26, 7+ months of pregnancy, vaginal bleeding

Discussion

Medical history collecting and writing

Pelvic examination

• Check carefully, gentle movement

• Urine evacuated before check ( urine preserved for checkup )

• Replace the one-time pad

• Bladder lithotomy position

Q: To avoid the menstrual period, what should you do before

check, if check is must while bleeding?

• Male doctor to check best with female physician presence to avoid unnecessary misunderstanding

Basic Requirements of the Pelvic Examination

Step 1

Vulval inspection

•Vulva development and its hair

distribution

•New biological, skin lesion vulva

•Vaginal vestibule

•Hymen

•The vagina mouth

•Vaginal wall and uterine prolapse or not

Step 2

Check up by speculum

• Speculum forbidden without

agreement by virgin

• replacement and removal

Step 3

Vaginal inspection

deformity: vaginal septum,

double vagina

new biological, ulcer, cyst or not

Vaginal discharge is normal, if

necessary, check leucorrhea

routine

Step 4

Cervical inspection

Size, color, mouth shape

bleeding, erosion, gland cyst, polyps

Cervical tube has hemorrhages or

exudates or not

Cervical smear

Cervical scraping smear

Step 5

Bimanual examination

Check with two fingers or one

finger into the vagina, while the

other hand in the abdomen to

help checking

Vaginal, cervical, endometrial,

attachment, palace and pelvic

wall

Step 6

Trimanual examination

Rectal, vaginal, abdominal

examination

Rectal - abdominal diagnosis

index finger into the rectum, with the

other hand in the abdomen helping

check

Asexual life history, vaginal atresia or

other reasons can not be performed

bimanual examination.

Check up Record

The vulva: development, production type.

Vaginal: Patency, mucosa, secretions

Cervical: size, hardness, erosion, contact bleeding, lifting pain

Uterine body: location, size, texture, motion, tenderness

Bilateral accessory: mass, size, texture, motion, tenderness,

and relationship between uterus and pelvic wall

1 Examination of vulva (5 points)

2 Speculum removal (5 points)

3 Speculum with lubricant (5points)

4Speculum two leaf close up (5 pints)

5Along the posterior wall to insert vagina speculum into the vagina,

gradually flattening, open two leaves, gentle action ( 10 points)

6 Exposure of the vaginal wall, cervical and fornix ( 10 points)

•Examination of the vaginal wall mucosa color, elastic

•The amount of vaginal discharge, character, color, smell

•Cervical size, mouth shape, erosion and polyps or not

Gynecological examination evaluation standard ( out of 100 points )Gynecological examination evaluation standard ( out of 100 points )

7 Speculum removal (5 points)

8 Wearing sterile gloves ( 5 points)

9 The index finger, middle finger stick lubricant ( 5 points)

10 Examination of vaginal, cervical, posterior fornix ( 15 points)

11 Bimanual examination ( 20 points)

12 The finger out of the vagina, disposable gloves,

the patient is asked to get dressed ( 10 points)

Gynecological examination evaluation standard ( out of 100 points )Gynecological examination evaluation standard ( out of 100 points )

Gynecological examination evaluation standard ( out of 20 points )Gynecological examination evaluation standard ( out of 20 points )

The end

Thank you !