HISTORY-TAKING & PHYSICAL EXAMINATION

BY DR SAMER ABU EIDEH

HISTORY TAKING

AGE

PATIENTS
NAME

EXPECTED
DATE OF
DELIVERY

RACE
IDENTIFICATION
DATA

PERIOD OF
GESTATION

GRAVIDITY

PARITY

HISTORY TAKING

LAST NL
MENSTRUAL
PERIOD

If she is pregnant we have also to

mention :
#gravidity : the No of pregnancies
irrespective of the outcome.

# parity the No of pregnancies

reaching the viable stage.

HISTORY TAKING

# abortion : the No of pregnanciec

terminated by any means before the
viable stage.
# MULTIPLE PREGNANCY IS ADDED AS A
SINGLE OCCURRENCE.
##Note :Definition of other terms may
used in history taken
# ENND = death in 1st week of life.
#NND= death within 28 days after
delivery.
# INFANTILE DEATH : during 1st year.
HISTORY
TAKING
# CHILD
DEATH
=from one year to 14 year.

# calculation of EDD and

gestational age :
#mentrual cycle have 2 phases :a follicular phase (variable in length) b
luteal phase (constant in length= 14
days).
# in a 28 day cycle ovulation occurs 14
days before expected next menstruation

HISTORY TAKING

Duration of
pregnancy(gestatio
nal age) calculated
using either

1- embryonic age( ovulation date)

( fertilization date ) which is calculated
from the time of conception and equals
~266 days in a full term pregnancy.
# gestational age (or menstrual
age)which is calculated from the 1st day of
the LMP ~ 280days or 40wks
# to calculate EDD we use the
NAEGELES rule

HISTORY TAKING

We add 7 days to the days of

the LNMP & we substract 3
mths or add 9mths.

NAEGELES rule can only be applied when:

# the cycle is regular of 28 days
# the lady is not lactating or on OCPs
= If the cycle is irregular then we use
the revised EDD (with short cycle the EDD
will be moved earlier, & with longer cycles
the EDD will be moved forward)

HISTORY TAKING

# to calculate the G.A at the time or

clercking, i we add 1wk for every 3mths
e.
g

A lady is currently in her

seventh pregnancy. She
delivered 3 children prior, with
1 of them was twin. She had
history of 1 miscarriage, 1
molar and 1 ectopic pregnancy.

she will be described as:

Gravida 7 Para 3(1 set of
twins) + 1 abortion + 1
ectopic + 1 molar

HISTORY TAKING

e.
g

Calculation of revised
EDD (REDD)
In a woman whose LNMP on
15/3/2008, with
menstruation occurs every
21 days, her EDD will be on
15/12/2008 instead of
22/12/2008.

HISTORY TAKING

e.
g

Calculation of period of
gestation
You see a lady whose LNMP was
on 1/2/2008 on 1/9/2008.
Therefore, she is at 30 weeks of
gestation. LNMP: 1/2/2008 Date
of clerking: 1/9/2008 There are 7
months (28 weeks) difference
between her LNMP and the date
you see her. Adding another 2
weeks to the difference (add 1
week for every 3 months), the
lady is now at 30 weeks of
gestation.

HISTORY TAKING

Chief
complai
nt

#describes the symptom or

problem that brings the patient to
see the doctor
#if there is more than one chief
complaint, they should be
arranged in a chronological order
according to time of occurrence.

HISTORY TAKING

Hx of
presentin
g illness

#the chief complaint is

elaborated under this heading
(describes the onset, nature,
aggravating and relieving factors
of the complaint and the
progression of the complaints
until you see the patient ).
HISTORY TAKING

Hx OF
PRESENT
PREGNAN
CY

#The details of present pregnancy

since diagnoses of pregnancy till now
,also the results of routine antenatal
investigations should also be
elicited.

HISTORY TAKING

PAST
OBSTETRI
C Hx

#The details of each previous

pregnancy must be described in
chronological order.
# The following information is
therefore important:
1. Year of delivery
2. Gestational age at delivery
3. Antenatal problems
4. Onset of labour (spontaneous or induced)
5. Mode of delivery
6. Complications occurred at delivery
7. Complications during postpartum period
8. Details about the baby: Babys gender Weight at
delivery Viability of baby (live birth or stillbirth) Baby

HISTORY TAKING

GYNAECOL
OGY Hx

Menstrual cycle of the patient is

recorded as follows: Age at menarche
Duration of bleeding
Length of
menstrual cycle
#Ask about menstrual problem such as intermenstrual
bleeding, menorrhagia or dysmenorrhoea
#ask about the past history of sepsis or sexually
transmitted diseases (STD)
#Cervical smear result should be asked and noted
#Any gynaecology operation such as D&C and
myomectomy should also been enquired
#A review on contraceptive history and when and why it
was stopped

HISTORY TAKING

PAST MEDICAL
AND
SURGICAL Hx

#Major medical problems such as

diabetes, HTN, heart disease,
renal disease & any psychiatric
problems should be asked
#Any surgical Hx should be
detailed separately

HISTORY TAKING

DRUG AND
ALLERGY Hx
# Details of the drugs (prescribed drugs,
OTC drugs, modern as well as traditional
medications) taken by the patient should
be elicited
# Some of the medications are
contraindicated to pregnancy and need
to be stopped, whilst some should be
continued but of different form or at
different dose
#History
of allergy
to any medication as
HISTORY
TAKING

FAMILY Hx

#Ask whether there has been any

congenital abnormality in the family
#Ask about family hx of diabetes mellitus,
hypertension, tuberculosis, multiple
pregnancy etc
#Some of the problems in the family can
be passed to the patient, thus putting them
at high risk to develop the same problem
during pregnancy
# Some of the diseases need the patient to
be screened during the current pregnancy

HISTORY TAKING

SOCIAL Hx

Employment
#home condition
#the length of relationship, are all of
great importance when assessing the
prospects for recovery from the
illness or the support of the child.

HISTORY TAKING

Systemic
review

Description about other symptoms

experienced by the patient that may be a
sequel of patients problem should be
recorded.
summa
ry
At the end of the history, a summary should
be prepared to state briefly the details of
the case
#Age, gravidity, parity, period of gestation and chief
complain are the most important information to be
stated
#Important positives and negatives points in
history should be briefly stated
#list of possible differential diagnosis for the

HISTORY TAKING

# you should never

examine any patient
alone.
#You should introduce
yourself to the Pt and
explain the purpose of
the examination.
# you should stand on
the right side of the
patient

PHYSICAL EXAMINATION

GENERAL
EXAMINATI
ON

hand
s

.look for
# pallor,
#palmar erythema (may be
normal during pregnancy),
# koilonychias(sign for iron
deficiency anemia),
#clubbing,
# peripheral cyanosis
#count the pulse rate of the
patient(note rate, rhythm &
volume).

PHYSICAL EXAMINATION

GENERAL
EXAMINATI
ON

arms
. Take blood pressure
#the cuff should be wide enough
to cover about 2/3rd of the arm
or upper thigh
#Patient should be seated with
the examination arm on the table
or she should rest comfortably on
her right side with 15 to 30 tilt
and the right upper arm is at the
level of the heart.

PHYSICAL EXAMINATION

GENERAL
EXAMINATI
ON

Eyes
#Examine the conjunctiva to look
for pallor, which is a sign of
anemia.
#Yellowish discoloration of the
sclera indicates jaundice
#look for exophthalmoses. Its
presence indicates thyrotoxicosis

PHYSICAL EXAMINATION

GENERAL
EXAMINATI
ON

Mout
h
#angular stomatitis indicates iron
deficiency anemia
#while glossitis indicates folate
deficiency. #Central cyanosis may
be present in patients with heart
disease.

PHYSICAL EXAMINATION

GENERAL
EXAMINATI
ON

Thyro
id

#The thyroid may

sometimes be enlarged,
reflecting increase
metabolism in pregnancy

PHYSICAL EXAMINATION

GENERAL
EXAMINATI
ON

Legs
#Examine the legs for
peripheral oedema. This sign
is elicited by pressing the
examining finger on the skin
over tibia for 10 seconds
#The presence of peripheral
oedema may be
physiological in pregnancy,
where hands and feet are
involved
#It may be pathological in
more severe degree where it
involves the face and sacral

PHYSICAL EXAMINATION

ABDOMIN
AL
EXAMINAT
ION
#Patient should lie flat or in a semi recumbent
position, with the head rested on one pillow (Beware
of supine hypotension)
#Patient abdomen should be exposed from the
xiphisternum to just below the symphysis pubis, to
display the suprapubic and inguinal regions with
sheet covering the legs up to just below the
symphysis pubis
A-inspection : we inspect for abdominal distension
or enlargement (symmetrical or non symmetrical) ,
linea nigra, striae gravidarum( indicate current
abdominal distension may be due to pregnancy),
striae albicans (indicate previous abdominal
distension either due to pregnancy or other

PHYSICAL EXAMINATION

ABDOMIN
AL
EXAMINAT
ION

B- PALPATION : you should be

gentle and keep looking on the
patient face during palpation to
be sure you are not causing
pain.

PHYSICAL EXAMINATION

ABDOMIN
AL
EXAMINAT
ION
1- superficial palpationusually we start from the left
lower quadrant using the flat of the hand and move
gently around the abdomen looking for points of
tenderness or rigidity or guarding.
#If there is rigidity, try to differentiate betwwen true
regidity and voluntary one (due to nervous )rigidity by
asking the patient to draw up her knees, this action will
relax the abdominal muscle.
#If there is tenderness, try to induce rebound
tenderness, by asking the patient to cough Or to push the
abdominal wall against the examining hand. This will
stretch the peritoneum out and cause discomfort in cases of
peritoneal irritation or inflammation

Note : sudden withdrawal of the hand to induce

rebound
tenderness should be avoided coz it may coz significant
distress to the patient .

PHYSICAL EXAMINATION

ABDOMIN
AL
EXAMINAT
ION
2- deep palpation we gently try to feel for
organomegally and In case of pregnancy we feel the
uterus and check either if it is soft and non tender
or it is rigid and tender , also we check for uterine
size , fetus and liquor.
#we also feel for the liver, epigastric and loin
tenderness .
#if there is a pelvic or abdominal mass : site , size ,
shape , consistency , mobility and tenderness should
be determined.
# we check for the presence of ascites ,a- shifting
dullness :percussion from midline to laterally untill
thepercussion changes from resonance to dull , we
keep the hand in this point and rool the patient 45
degrees , then we repeat percussion over this point
which changes to reasonance in the presence of

PHYSICAL EXAMINATION

Symphysio
fundal height

ABDOMIN
AL
EXAMINAT
ION

#It is the distance between the fundus of uterus to top of

symphysis pubis.
#It can be estimated clinically or measured in centimeters
#Clinical estimation of uterine size is done as below:
At 12 weeks of gestation, the fundus is just above the symphysis pubis
At 16 weeks, the fundus is equidistance between the symphysis pubis and
umbilicus
At 22 weeks of gestation, the fundus is at umbilicus
At 30 weeks, the fundus is equidistance between the xiphisternum and
umbilicus
At 36 weeks, the fundus is at xiphisternum,

To measure (SFH) in centimeter

first centralize the uterus if it is deviated then a tape is used to measure the distance
between the
Fundus of uterus and the uppermost part of symphysis pubis .
After 20 weeks the SFH approximates to the number of weeks
Measurement of SFH cannot be done if pregnancy is less than 20 weeks.

PHYSICAL EXAMINATION

Symphysio
fundal height

ABDOMIN
AL
EXAMINAT
ION

PHYSICAL EXAMINATION

THE NUMBER OF
FETUSES

ABDOMIN
AL
EXAMINAT
ION

#Face the patient head and palpate the fundus and letral
walls of uterus using the flat of both hands to determine
the No of fetal poles , then face the patient feet and
papate the lateral walls toward symphysis pubis . Single
fetus has 2 poles , presence of more than 2 poles indicate
multiple pregnancy , also may indicate singleton pregnancy
with uterine fibroid or ovarian mass.

PHYSICAL EXAMINATION

THE NUMBER OF
FETUSES

ABDOMIN
AL
EXAMINAT
ION

PHYSICAL EXAMINATION

Fetal lie

ABDOMIN
AL
EXAMINAT
ION

#The relationship between the long axes of

the fetus to that of the mother
#It can be longitudinal , transverse or
oblique
# fetal lie is determined after determination
of fetal poles .

PHYSICAL EXAMINATION

Fetal
presentation

ABDOMIN
AL
EXAMINAT
ION

the fetal part that is foremost in

the birth canal ,,
#By facing the patients feet, apply lateral
palpation to the presenting part gently
pressing fingers of each hands towards the
pelvis to determine whether the presenting
part is cephalic (fetal head is hard and round)
or breech( fetal breech is soft and not so
round) and whether it is fixed or mobile
#With trans- verse or oblique lie, we may feel
either shoulder or arm.

PHYSICAL EXAMINATION

ABDOMIN
AL
EXAMINAT
ION

PHYSICAL EXAMINATION

Fetal parts

ABDOMIN
AL
EXAMINAT
ION

#The fetal parts is assessed by

performing lateral palpation to
dtermine on which
Side the back of the fetus(firm)
located,
and fetus belly (soft) and limbs
are
located

PHYSICAL EXAMINATION

ABDOMIN
AL
EXAMINAT
ION

PHYSICAL EXAMINATION

ABDOMIN
AL
EXAMINAT
ION

c- percussion.

PHYSICAL EXAMINATION

ABDOMIN
AL
EXAMINAT
ION
D- auscultation :
auscultation of fetral heart using Pinard
fetal stethoscope depends on fetal
presentation and location of fetal back
A- If the presenting part is cephalic, the
fetal heart will be heard over the lower
right or lower left of the maternal
abdomen
B-If the presenting part is breech, the
fetal heart will be heard over the upper
right or upper left of the maternal
abdomen.
# we auscult also for bowel sound ,
silent abdomen indicate intestinal
paralysis .

PHYSICAL EXAMINATION

#pelvic examination :
Patient placed in dorsal position with both knees
bend and apart.
A- inspection : we inspect for , swelling , inflammation , masses
, lesions , discharges , trauma, skin tags , hemorrhoids and fissures.

B- speculum examination : done with the patient either in

dorsal or lateral position. The cervix is inspected for the presence of
masses , discharge and ulcerations.

C- vaginal examination :

its done with lubricated gloves ,

vaginal walls palpated for the presence of masses , uterine cervix is
felt for it,s position , presence of masses , in cases of pregnancy
whether its closed or dilated , consistency , degrees of dilatation ,
condition of fetal membranes , presenting part and station of
presenting part.

D- bimanual examination :
fingers of right hand placed in the vagina and the left hand is placed
over
the abdomen above symphysis pubis and bellow the umblicus .
# cervix is identified and moved gently to asses for excitation pain
# palpation of uterus : fingers of right hand placed under the cervix
and
gently push up on the cervix to tilt the uterus upward and be felt
between the two hands , in pregnant women uterus is soft as lips ,
while in non-pregnant women the uterus is firm like the tip of the
nose .
# position of the uterus : in anteverted uterus the cervix is
directed in
posterior position and the anterior lip of the cervix is felt 1 st ,
while in
retroverted uterus , the cervix is directed in anterior position
and the
posterior lip of the cervix is felt 1 st .

# the adenxae is palpated for tenderness or masses , if mass

present , its size ,
consistency , mobility , shape and tenderness should
determined.
# finally , size , shape , consistency and mobility of ovaries
should be
determined .

Thank you