History taking of a patient who has come to your OPD plays a very important role.
Detailed history taking and thorough clinical examination and relevant investigations will give the accurate diagnosis and helps in the management of cases.
OBSTETRICS
History
- To assess the health status of the mother and the fetus.
- To assess fetal gestational age and to obtain baseline investigations.
- To organize continued obstetric care and risk assessment.
- Name: Identification of the patient
- Wife of:
- Marital status:
- Date of first examination:
- Address (along with contact number):
- Age: Extremes of age, i.e. teenage and elderly (30 or above) are obstetric risk factors
- Gravida: Pregnant state, both present and past, irrespective of gestational age.
- Parity: State of previous pregnancy beyond the period of viability
- Gravida and para both refer to pregnancies and not live babies
- Duration of marriage: Relevant to note the fecundity or fertility
- Religion
- Occupation: For interpreting the social status
- Occupation of the husband.
- To obtain an idea regarding affordability of the treatment provided
- To give proper antenatal advice regarding family planning.
- Period of gestation in the diagnosis—to be expressed in terms of completed weeks.
Calculation
In early weeks of gestation, counting is done from first day of last menstrual period and in later weeks, it is done from the expected date of delivery.
Start the presentation noting her gravida, para status and duration of amenorrhea in months as presentation and never as complaint, e.g. A G2P1L1 presenting with amenorrhea of 8 months…….
If a pregnant lady has no complaints, it can be presented as admitted for safe confinement, if with complaints the nature and duration of complaints may be mentioned.
In a term pregnant lady, pain abdomen, features suggestive of preeclampsia, symptoms suggestive of labor need to be enquired like, leak per vaginum (PV), bleeding PV, headache, blurring of vision, etc. Perception of fetal movements can assure to some extent about the fetal well-being.
Chief Complaints
Categorically, the genesis of complaints are to be noted. If there are no complaints, general enquiry about her well-being has to be made,
e.g. history of leak PV, bleed PV; history of pain abdomen.
History of Presenting Illness
Elaboration of the chief complaints has to be done regarding the onset, duration, severity, progression and use of any medications. History of pain abdomen (details need to be taken to differentiate between true and false labor pains, UTI, etc.).
Obstetric History
Married life and query about consanguinity has to be made (infertility, precious pregnancy, causes for congenital anomalies, etc.).
Parity Index
Mention about gravidity, parity, living issues, abortions (GPLA).
It is summed up as: status of gravida, parity, number of deliveries, abortions (including MTPs) and living issue (Table 1).
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For example, G3P1L1A1
- List out the significant events during each trimester based on the duration of pregnancy.
- Enquire about the duration from last pregnancy/last abortion.
- History of any contraceptive usage between last childbirth/abortion and present pregnancy.
- Rh-negative pregnancy—history of previous pregnancies and administration of anti-D immunoglobulin previously.
History of Present Pregnancy
*Number of antenatal visits (booking status) and immunization status has to be noted.
Women with at least 3 antenatal visits, who have received 2 doses of injection TT and taken 100 tablets of iron and folic acid (with ultrasound desirable but not mandatory) are said to be booked.
- Number of antenatal visits
- Ideal: Once every four weeks in the first 28 weeks, every 2 weeks till 36 weeks and weekly after 36 weeks.
- To decrease the load in antenatal clinics, RCH program has advised 3 antenatal visits in an uncomplicated pregnancy at least once in each trimester with an additional visit in the 3rd trimester:
- As soon as she becomes pregnant
- Once in 2nd trimester
- At 32 weeks.
- At 36 weeks or once in the last trimester.
WHO Recommendation—minimun 4 visits 1 at 16 weeks, 28 weeks, 32 and 36 weeks.
However, in case of high-risk pregnancies, the number of visits can be increased/individualized based on the patient's condition.
For example:
1st Trimester
Symptoms of hyperemesis, threatened abortion, etc. Any medication or radiation exposure, fever with rashes (congenital rubella syndrome), UTI during first trimester has to be enquired along with any medical or surgical events during pregnancy.
2nd Trimester
Date of quickening needs to be asked for symptoms of UTI, GDM, etc.
3rd Trimester
- Symptoms of anemia, preeclampsia.
- History of leaking PV, pedal edema, pain abdomen—to differentiate between true and false labor pains (Table 2).
Menstrual History
Previous cycles: Duration and amount of flow.
LMP: First day of last normal menstrual period
EDD: Expected date of delivery.
Calculation: As per Naegele's formula it is obtained as follows (in regular cycles):
EDD = LMP + (9 months) + 7 days.
High-quality ultrasound measurement of the embryo or fetus during the first trimester of pregnancy is the most accurate method of establishing or confirming gestational age.
If the pregnancy is the result of assisted reproductive technology (ART), the clinician should use the ART-derived gestational age to assign the EDD. For example, for a pregnancy that results from in vitro fertilization, the clinician should use the age of the embryo and the date of the transfer to establish the EDD.
As soon as the clinician has data from the last menstrual period, the first accurate ultrasound examination, or both, the gestational age and the EDD should be calculated, discussed with the patient, and recorded clearly in the patient's medical record.
For research and surveillance purposes, the clinician should use the best obstetric estimate, rather than calculations based only on the last menstrual period, to determine gestational age.
Subsequent changes to the EDD should only be made in rare circumstances, should be discussed with the patient, and should be recorded clearly in the patient's medical record.
Past History
Medical
TB, asthma, hypertension, DM, epilepsy, cardiac disorders, thyroid disorders.
Surgical
General/gynecological.
Family History
Personal History
Enquire about diet, appetite, sleep, bowel and bladder habits and any health affecting habits. Previous history of blood transfusion, steroid therapy, drug allergy.
Importance
- Anemia in pregnancy (advice is to be given to have food rich in iron, folate, vitamin B12)
- Diabetes in pregnancy—diet for maintainance of sugar levels and for decision regarding insulin dosage.
Summary
Mrs X aged ______ years, w/o ____________ with socioecomic status _____ with ________ period of gestation has come with complaints of ____________
Provisional Diagnosis
Examination
General Physical Examination
- Build—obese/average/thin.
- Nutrition—good/average/poor.
- Height—short stature is likely to be associated with a small pelvis (4.7 feet or lesser is considered to be short stature in India).
- Weight—for adequate weight gain during pregnancy (Table 3).
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Range of weight gain
- Women carrying twins—16–20 kg
- Young adolescents—weight gain at upper end of the range
- Short women—weight gain at the lower end of the range
Rate of weight gain in the second half of pregnancy is 500 g/week.
(BMI becomes important or is of value only when prepregnancy weight is known)
- Pallor, icterus, cyanosis, clubbing, lymphadenopathy or edema
- Tongue, gums, teeth and tonsils—for evidence of infections, malnutrition (glossitis, cheilosis, bald tongue, etc.)
- Neck—neck veins, lymph nodes and thyroid examination.
- Edema of legs—pitting type.
It could be physiological or pathological due to preeclampsia, anemia with hypoproteinemia, cardiac failure or nephrotic syndrome or hepatic failure.
Vitals
Pulse Rate
- BP—disappearance of sounds (Korotkoff 5) is taken as the representation of DBP in pregnancy (because of presence of large fistula at the placental site)
- Temperature if relevant/required
- Respiratory rate and type of respiration.
Systemic Examination
- CVS—S1S2 + presence/absence of murmurs
- RS—bilateral NVBS heard, no added sounds
- CNS—within normal limits.
- Breasts—to be examined for presence of any lesions/growth/mass.
See for normal pregnancy changes— increase in size of breast, montgomery tubercles, secondary areola.
Nipples size and shape need to be assessed for breastfeeding postpartum.
Positions
- Arms by the sides (A)
- Arms raised above the head (B)
- Hands pressing against waist (to contract pectoral muscles) (C)
- Abdomen—for any palpable organs.
Obstetric Examination
A verbal consent is taken for the examination and the abdomen is fully exposed.
Position
Dorsal with thighs slightly flexed.
The examiner stands on the right side of the patient.
Inspection
To note:
- Whether the uterine ovoid is longitudinal, transverse or oblique
- The contour of the uterus—fundal notching, convex or flattened anterior wall, cylindrical or spherical shape
- Any undue enlargement of uterus
- Any skin changes over the abdomen or scar marks over the abdomen
- Fundus of the uterus is just palpable over the symphysis pubis at 12 weeks.
Palpation
- Height of the uterus—uterus is centralized if it is deviated. The ulnar border of the left hand is placed at the uppermost level of the fundus and an approximate duration of pregnancy is ascertained in terms of weeks of gestation
- SFH can be measured with a tape.
Obstetric Grips (Leopolds Maneuver)(Fig. 1)
- Fundal grip: Palpation is done facing the patient's face. The whole fundal area is palpated using both hands laid flat on it to find out which pole of the fetus is in the fundus.
- Broad, soft, irregular mass: Breech
- Smooth, hard, globular mass: Head
- Neither of the poles palpated in the fundus: Transverse Lie
- Lateral or umbilical grips: Palpation is done facing the patient's face.Hands are placed flat on either side of the umbilicus to palpate one after the other, the sides of the uterus to find out the position of back, limbs and anterior shoulder from above downwards.
- Smooth, curved, uniformly resistant feel—back
- Irregular knob like structures—limbs
- First pelvic grip (Leopold's third maneuver):Done by facing the patients face to ascertain presenting part, attitude, ballotabiltyThe outstretched thumb and four fingers of the right hand are placed over the lower pole of the uterus, keeping the ulnar border of the palm over pubic symphysis to ascertain the presenting part and engagement. The unengaged head can move freely from side to side and both the poles remain at the same level.
- Second pelvic grip (Pawlik's grip or Leopold's fourth maneuver):It is done facing the patient's feet.Four fingers of both the hands are placed on either side of the midline in the lower pole of the uterus and parallel to inguinal ligament. The fingers are pressed downwards and backwards in a manner of approximation of finger tips to palpate the part occupying the lower pole of uterus.Engagement of head: Head is engaged when the greatest horizontal plane, the biparietal diameter, has passed the plane of pelvic brim.
Per Speculum Examination
Look for any:
- Leak PV (in cases of PROM)
- OS open/closed (preterm, incomplete/inevitable abortion)
- Cervical length (preterm).
Per Vaginal Examination
- Cervix—position, consistency, effacement in cm, dilatation of cervical os presenting part—station, position
- Presence/absence of membranes
- Pelvic assessment (done in primigravidas by 38 weeks in multigravida previous uncomplicated vaginal delivery itself is a proof of adequacy of pelvis)
- Points to be noted in pelvic assessment
- Sacral promontory
- Sacral curvature
- Sacrosciatic notch
- Ischial spines (prominent/not)
- Subpubic angle
- Intertuberous diameter.
GYNECOLOGY
History
- Importance toward maintenance of patient—physician relationship
- Allow the patient to talk about her chief symptoms
- After that, ask the patient series of direct and detailed questions concerning her symptoms
- Name—for the identification of the patient
- Wife of
- Age—some disorders are common in certain age groups; helpful in narrowing down the differential diagnosis.
- Childhood—foreign body, vaginitis, ovarian tumors
- Adolescence—menstrual disorders, uterovaginal anomalies, PCOS, precocious/delayed puberty, germ cell tumors
- Reproductive age group—menstrual disorders, infections, benign lesions of genital tract, pregnancy related problems
- Older age—menopause related problems, malignancies.
- Address (along with contact No.)
- Social status
- Anemia is known to be more common in lower social strata
- Affordability of treatment becomes an influential factor in management.
- Chief complaints—to be taken in detail and in chronological order. Common complaints are amenorrhea, abnormal vaginal bleed, dysmenorrhea, pain abdomen, mass felt per abdomen, vaginal discharge, mass per vagina, inability to conceive, urinary symptoms, genital ulcers/swellings.
History of Presenting Illness
- Elaborate chief complaints
- Associated/related symptoms
- General symptoms like recent weight loss/gain/fever/fatigue
- Bladder/bowel symptoms.
Pain Abdomen
SOCRATES
S–site
O–onset
C–character
R–radiation
A–associations
T–time
E–exacerbating factors
S–severity.
Menstrual History
- Age of menarche
- Duration of a period
- Length of cycle
- Intermenstrual bleeding (always pathological).
If present conditions like cancer cervix, cancer endometrium, intrauterine device, foreign bodies, fibroid polyp need to be ruled out.
- Dysmenorrhea—enquire if it occurs before, during or after the cycles.
- Amount of bleeding:
- If excess
- Pictorial blood loss assessment chart.
Pads | Factor | 1 | 2 | 3 | 4 | 5 | 6 | 7 |
|---|---|---|---|---|---|---|---|---|
X 1 X 5 X20 | II III III | I II I | I II | |||||
Total | 87 | 31 | 11 |
- Pads:
- Lightly soaked—multiply by factor 1
- Moderately soaked—multiply by factor 5
- Heavily soaked—multiply by factor 20.
In case of usage of tampons, multiply by 1,5 and 15.
Total score >100
Heavy Menstrual Bleeding
- In case of menopause ask regarding
- Menarche
- Postmenopausal bleed (importance is to rule out malignancies like cancer cervix or cancer endometrium)
- Menopausal symptoms—vasomotor, mood, urinary symptoms, etc.
- Calcium intake.
Obstetric History
- Marital status
- Consanguinity
- Parity
- Details of each pregnancy
- Years and events
- Pregnancy related events
- Mode of delivery
- Puerperal events
- Baby details
- Duration of breastfeeding
- Duration of contraceptive usage
- Number of miscarriages/molar pregnancies
- Nulliparous—most common: Endometriosis, endometrial cancer, breast ancer
- Multiparous—most common: Adenomyosis, cervical cancer, pelvic organ prolapse
- Recent delivery or miscarriage—sepsis, RPOC.
Contraceptive History
- Combined OCPs—protective against ovarian and endometrial cancer
- IUCD—can cause HMB, dysmenorrhea
- LNG-IUS—can cause amenorrhea.
Sexual History (in Case of Infertility)
- History of cohabitation (gaining importance these days due to changing trends in lifestyle)
- Vaginismus
- Sexual satisfaction or orgasm
- Dyspareunia
- Vaginal dryness
- In husband, premature ejaculation, erectile dysfunction.
Past History
Medical
Diabetes, thyroid disorders, epilepsy, TB, cardiac disease and others (influential in the management of cases).10
Surgical
- Breast surgery (fibroadenoma), pelvic surgery (for adhesions), surgery for inguinal hernia in childhood (androgen insensitivity).
- Any hospital admission.
Family History
- Familial cancers—ovarian, endometrial, breast
- Any medical disorders
- Any infectious diseases.
Summary
Miss/Mrs X aged ___ years belonging to socioeconomic status _____ has come with complaints of _________
Provisional Diagnosis
Examination
General Physical Examination
- Built—obese/thin—to rule out endocrinopathy, menstrual abnormality.
- Obesity can lead to CAD, hypertension, diabetes, etc. which are risk factors for endometrial cancers.
- Nutrition—average/normal.
- Development of secondary sexual characters—breast, axillary hair, pubic hair.
- Height, weight, BMI
- Evidence of pallor, icterus, cyanosis, lymphadenopathy (cervical, left supraclavicular, axillary and inguinal) or edema.
- Examination of neck—thyroid enlargement, lymphadenopathy.
- Teeth, gums, tonsils—for septic foci, important before general anaesthesia is being given.
- PR, BP, RR.
- Examination of spine (important while performing surgeries during spinal anesthesia).
Breast Examination
- To be done in all women aged more than 40 years, as breast carcinoma is the second most common malignancy in females.
Positions
- Arms by the sides (A)
- Arms raised above the head (B)
- Hands pressing against waist (to contract pectoral muscles) (C).
Inspection
Look for dimpling of skin, erythema, edema, nipple retractions, nipple eczema.
Palpation
Look for nipple discharge, palpable mass/nodes (E).
Systemic Examination
- Cardiovascular system
- Respiratory system
- Central nervous system
Abdominal Examination
Inspection
- Distension/ascites
- Umbilical position
- Presence of scars
- Presence of dilated veins/sinuses/visible peristalsis
- Discoloration over umbilical area/flanks
- Presence of hernia or divarication of recti.
Palpation
- Areas of tenderness
- Organomegaly
- Mass—size, shape, surface, site, extent, margins, mobility, consistency (mass arising from pelvis—cannot get below the mass, lower border cannot be made out because of the presence of symphysis pubis).
Percussion
- Presence of fluid thrill, shifting dullness—to look for evidence of free fluid
- In ascites—fluid thrill and shifting dullness will be present
- In an encysted/a large ovarian cyst—no shifting dullness.
Auscultation
Presence of hypoactive/hyperactive bowel sounds.
Pelvic Examination
Instruct the patient to empty her bladder before performing pelvic examination.
Various positions
- Dorsal—patient lying supine with legs flexed at hip and knee with feet resting on examination couch
- Lithotomy—supine with patient's legs in stirrups
- Sims’—left lateral position with left leg extended and right leg flexed at knee and hip and left arm by the side of patient
- Lateral position.
Prerequisites
- Patient should have emptied the bladder
- Female attendant should be present (in case of male examiner)
- A good light source
- Sterile gloves, sterile lubricants and instruments
- Consent from parent or guardian in case of examination of a minor or unmarried.
(In case of minor, it is better not to do digital vaginal examination if there is no absolute indication).
Vulvovaginal Examination
Inspection
- Vulva
- Pubic hair distribution
- Skin lesions—color changes, ulcer, swelling, growth
- Introitus
- Clitoris
- Hymen
- Descent of uterus or cervix—ask to strain to elicit stress incontinence, genital prolapse, perineal tears, hemorrhoids, anal fissures or anal fistula
- Perineal body
- Anus.
Palpation
Urethral discharge, Bartholin's glands, levator ani tear.
Speculum Examination
Labia minora are separated first and then Cusco's or Sims’ speculum is introduced as follows (Figs 6 and 7):
- Blade is introduced along the longitudinal axis of vagina, firstly.
- Blade is then turned 90° and vagina and cervix are examined.
Vagina
- Presence of blood
- Discharge to be collected to detect monilial, trichomonal, chlamydial and gonococcal infections
- Dryness
- Mucosal characteristics—color, vascularity, edema, etc.
- Growth
- Structural abnormalities (anterior vaginal wall cysts, vaginal septum).
Cervix
- Color—normally pink
- External os—round in nulliparous, transversely slit in multiparous
- Position—posterior/mid position, anterior
- Discharge—s/o infections
- Bleeding through os
- Tears and lacerations
- Nabothian follicles or cysts
- Erosions
- Bleeding on touch.
Bimanual Examination (Abdominopelvic Examination)
- Introduce well lubricated gloved index and middle fingers into the vagina
- Place the other hand over the infraumbilical region of abdomen and gently press while sweeping the pelvic structures towards the fingers palpating the abdomen
- Coordinate the activity of two hands to evaluate the following.
Uterus
- Position—anteverted/retroverted/midposition
- Size—normal/enlarged
- Shape—regular/irregular
- Consistency—soft/firm
- Mobility—mobile/fixed/restricted
- Tenderness—absent/present
- Tumors if found, size, location, number, shape, consistency, tenderness, mobility, relation with uterus, transmitted mobility.
Cervix
Position, consistency, os open or closed.
Adnexa (Table 4)
- Presence of mass
- Normally tubes are not palpable and rarely normal ovaries are palpable.
- Adnexal mass has to be evaluated for, size, shape, consistency, tenderness, mobility, nodularity relation with uterus and cervix, transmitted mobility.
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Bimanual Examination of Uterus (Fig. 8)
Consistency
- Soft—pregnancy, pyometra
- Hard—malignancy, calcfied myomas.
Enlargement
- Regular—pregnancy, adenomyosis, pyometra, hematometra, etc.
- Irregular—myoma, endometriosis.
Mobility
- Mobile—myoma, adenomyosis, pregnancy
- Fixed/restricted—PID, endometriosis, malignancy.
Per Rectal Examination
This is commonly not done.
It is done when Ca cervix, Ca endometrium, Ca ovary or endometriosis are being suspected clinically.
To look for any abnormalities in:
- Rectal mucosa.
- Parametrium.
- Uterosacral ligaments (endometriosis).
Examination under anesthesia
It is done for the examination of carcinoma cervix and endometrium.
Other modern, advanced modes of diagnosis have replaced this examination.
Rectovaginal Examination (Fig. 9)
It is done in case of suspicion of fistulae and cancers.
Bibliography
Obstetrics
- Bedside Obstetrics and gynaecology by Richa Saxena, 2nd edition.
- DC Dutta Textbook of Obstetrics.
- Practical Manual of Obstetrics and Gynaecology for PG Examination (Jaypee Publications).
- Practical Obstetrics and Gynaecology by Parulekar.
- Williams Obstetrics, 24th edition.
Gynecology
- Berek and Novak's Gynaecology.
- DC Dutta Textbook of Gynaecology.
- Jeffcoates Principles of Gynaecology.
- Lakshmi Sheshadri Textbook of Gynaecology.
- Practical Manual of Obstetrics and Gynaecology for PG Examination (Jaypee Publications).
- Shaws Textbook of Gynaecology.