HISTORY

PHYSICAL EXAMINATION

PGI DE GUZMAN, LYLE ANTHONY

“ The first contact a physician has with a
patient is critical. It allows an initial bond
of trust to be developed on which the
future relationship may be built.”
 HISTORY
PE

CLINICAL IMPRESSION

PLAN OF MANAGEMENT:
DIAGNOSTICS
THERAPEUTICS
HISTORY
 General history
 Chief complaint
 Past medical history
 Family history
 Personal and social
 Review of systems

PHYSICAL EXAMINATION
 General PE
HISTORY
 The patient will share sensitive information,
feelings, and fears.
 The physician will gain her confidence and
establish rapport by the understanding and
non-judgmental manner in which he or she
collects these data.
 The obstetrician-gynecologist should not
assume that the patient’s general medical
needs are cared for by others but should
assume the role of her primary physician.
 HISTORY
A. General Data

 Name  Religion
 Age  Address
 Sex  Admission
 OB score (1st, 2nd, etc.)
 Marital Status  Date
 HISTORY
B. Chief Complaint

 The present, main problem

 In the patient’s own words
 Do not use technical terms
HOW TO ELICIT THE CHIEF COMPLAINT

“How may I help you?”

“What brings you to the clinic today?”

“Ano po ang maitutulong ko sa inyo?”

“Ano po ang dahilan at kumunsulta kayo ngayon?”

“Why are you here?” “Bakit kayo nandito?”

“What is it?” “Ano iyon?”

 HISTORY
C. Past Medical History

 Chronological order
 Conditions not related to present illness
 Hospitalizations
 Surgical procedures and results
 Chronic diseases and treatment
 Bleeding / clotting problem
 PTB, DM, HPN, hepatitis, RF, etc.
 Past and current medications
 Drug and food allergies
 HISTORY
C. Past Medical History

 Surgery, trauma, blood

transfusions
 Gynecologic surgical procedures
 Biopsy, D & C
 Laparoscopy
 Except OBSTETRIC procedures

• (+) HPN since 2002, on Metoprolol 50 mg OD

(BP range = 130-140/80-90)
• (-) food / drug allergies
 HISTORY
D. Family Medical History

 Health status of the first order relatives

 History of similar illness or symptom
 History of hereditary diseases
 Diabetes  Heart disease
 Hypertension  Cancer

• (+) DM - mother
• (-) HPN, heart disease, CA
 HISTORY
E. Personal & Social History

 Summary of the patient’s life which may

be relevant or contributory to the present
condition / illness
 Educational attainment
 Occupation (patient & husband)
 HISTORY
E. Personal & Social History

 Habits
 Smoker: # of pack years, even if she does not
smoke anymore
 Alcoholic beverage drinker: quantity,
frequency
 Illicit drug use: type of drug, duration, quantity,
frequency
 Sexual Practices: age at first coitus, # of past
& current partners, if patient or partner is
promiscuous or not, contraceptive methods
 HISTORY
E. Personal & Social History

• The patient is a college graduate, employed

as a bank teller.
• She is a non-smoker and occasional
alcoholic beverage drinker.
• First coitus at age 22.
• She has 1 non-promiscuous sexual partner.
• (-) contraceptive use
 HISTORY
F. Menstrual History

 LMP
 LMP: date of 1st to last day of LAST NORMAL
MENSTRUAL PREIOD (moderate-strong flow)
 HISTORY
F. Menstrual History

Menarche at age 11. Subsequent menses at

regular 28 – 30 day cycles, 4 days duration,
consuming 3 – 4 pads / day.
LMP: November 3 – 6, 2007
PMP: October 5 – 8, 2007
(-) dysmenorrhea
 HISTORY
G. Obstetric History

 OB score
 G __ P __ ( __ - __ - __ - __)
 G: Gravidity (total number of pregnancies 
including full term, preterm, and abortions)
 P: Parity (total number of deliveries 
including full term and preterm)
 Full term – preterm – abortion – living children
 HISTORY
H. Review of Systems

 HEENT
 Cardiovascular / respiratory
 Gastrointestinal
 Genitourinary
 Neurologic / neuromuscular
 Vascular (thrombophlebitis, etc.)
 Psychiatric
 Review of System
 Constitutional symptoms: (+) significant weight change, (+)
fatigability, (-) generalized body weakness, (-) fever, (-) chills,
(-) change in appetite

 Skin: (-) itchiness, (-) excessive dryness, (-) change in color

 Head: (-) headache, (-) dizziness, (-) vertigo

 Eyes: (-) pain, (-) blurring of vision, (-) double vision, (-)
lacrimation, (-) photophobia

 Ears: (-) earache, (-) deafness, (-) tinnitus, (-) ear discharge

 Nose and Sinuses: (-) change in smell, (-) nose bleeding, (-)
nasal obstruction, (-) nasal discharge, (-) pain over Para nasal
sinuses
 Mouth and Throat: (-) toothache, (-) gum bleeding, (-)
disturbance in taste, (-) sore throat, (-) hoarseness

 Neck: (-) pain, (-) limitation of movement, (-) presence

of mass

 Breast: (-) pain, (-) lumps, (-) nipple discharge

 Cardiovascular: (-) substernal pain, (-) palpitations, (-

) paroxysmal nocturnal dyspnea, (-) orthopnea, (-)
syncope, (-) easy fatigability

 Gastrointestinal: (-) abdominal pain, (-) nausea, (-)

vomiting, (-) dysphagia, (-) diarrhea, (-) constipation, (-
) hematemesis, (-) melena, (-) hematochezia, (-)
regurgitation
 Genitourinary: (-) dysuria, (-) urinary frequency, (-) urgency,
(-) hesitancy, (-) polyuria, (-) hematuria, (-) incontinence, (-)
genital pruritus, (-) urethral discharge

 Extremities: (-) edema, (-) swelling of joints, (-) stiffness, (-)

numbness, (-) intermittent claudication, (-) limitation of
movement

 Neurologic: (-) headache, (-) vertigo, (-) syncope, (-) loss of

consciousness, (-) focal weakness, (-) paralysis, (-)
numbness, (-) paresthesia, (-) speech disorder, (-) loss of
memory, (-) confusion

 Hematologic: (-) bleeding tendency, (-) pallor, (-) easy

bruising

 Endocrine: (-) intolerance to heat and cold, (-) excessive

weight gain or weight loss, (-) polyuria, (-) polydipsia
 History taking is an art.
 Building patient rapport is vital.
 Start the interview by greeting your patient &
introducing yourself.

 The patient should feel that you see her as a

whole person and not just a history that has to
be completed.
 The sequence of questions will not necessarily
follow the format of the written history.
 After the patient relates her chief complaint, she may
proceed to the history of the present illness.
 It may take time before some sensitive
questions can be asked (sexual practices,
history of STD, nature of past abortions).

 If the patient seems to be deviating from the

history & relating unnecessary details, you
may re-direct her in a gentle, subtle way.
PHYSICAL EXAM
GENERAL PHYSICAL EXAM

 The physician should perform a complete

physical exam on the first visit, and at each
annual check-up.

 It is the time to gather information about the

patient and to teach her what she should
know about her body and her health.
GENERAL PHYSICAL EXAM

 The patient should wear a gown that will

ensure warmth and modesty.

 Presence of an assistant (third party)

 Offers warmth, compassion, and support to the
patient during uncomfortable and potentially
embarrassing portions of the exam
 Assists the physician in doing procedures
 Protects the physician from having his / her
intentions misunderstood by the patient
GENERAL PHYSICAL EXAM

A. General survey E. Chest

B. Weight, height • Lungs
BMI = weight in kg * • Heart
height in m 2 • Breast
C. Vital signs F. Abdomen *
D. Head and Neck; EENT G. Extremities
 Physical Examination
 General Survey
 The patient is alert, awake, well-kempt and
neat
 The patient looks congruent with his stated
age, is oriented to time, place and person
 Cooperative and accommodating, no speech
problems noted, no gross deformity seen, has
congruent mood and affect
 body built is hyposthenic, gait is normal, can
walk without difficulty and assistance.
GENERAL PHYSICAL EXAM

 BMI = weight in kg
height in m 2

 EX: weight = 50 kilos

height = 1.5 m

= 50 / 1.5 2
= 22.22
 Skin
 Skin is brown, slightly moist, elastic and
mobile and slightly thick.
 Has visible dilated blood vessels on the
dorsum of the palm and at the inner forearm
 No lesions noted.
 Hair is black, smooth, thin and evenly
distributed.
 The nails are pink, smooth, normal and intact
nail folds and no lesions.
 Head and Neck
 Cranium
 Head is normocephalic
 Thick black hair, evenly distributed
 Coarse and dry, clean scalp
 (-) dandruff, lice, mass and tenderness
 Not visible temporal arteries but palpable with
strong equal pulsations
 Face
 Oval, Normal Facie
 (-) lesions
 (-) involuntary movements
 (-) facial assymetry

 Eyes
 Anicteric sclera
 Pink palpebral conjunctiva
 (-) lesions
 Pupils equally rounded, reactive to light and
accomodation
 Opthalmoscopy: (+) ROR, no papilledema
 Ears
 Symmetric Auricles
 (-) deformities, lesions and tenderness
 Mastoid: (-) tenderness
 Otoscopy: pinkish external canal, patent
and (-) discharge
 Tympanic membrane is pearly white,
intact, flat and translucent
 (+) visible cone of light
 Nose and Paranasal Sinus
 Symmetrical nose
 (-) alar flaring
 Pinkish nasal septum, straight at the
midline
 (-) lesions, perforation and discharge
 Nasal cavity is patent, pinkish and
turbinates are flat and dry
 (-) tenderness on frontal and maxillary
sinuses
 (+) transillumination of Frontal and
Maxillary sinuses
 Oral Cavity
 Lips are pinkish, moist, no lesions and symmetric
 Buccal mucosa and gums are pinkish, smooth
and no lesions
 Upper teeth: has 2 canine, 4 incisors and 2 molar
teeth
 Lower teeth: has 1 canine, 4 incisors and 2 molar
teeth
 Tongue is symmetric, pinkish with rough papillae,
can move from side to side
 Hard and soft palate are pinkish with no lesions
 Uvula at midline
 Tonsils are not enlarged, no exudates
 Posterior pharynx is pinkish, no lesions and no
exudates
 Neck
 Normal in size
 Symmetrical
 (-) visible and palpable mass, lesions,
tenderness
 Trachea in midline, thyroid gland not visible or
palpable
 (-) carotid bruit

 Lymph Nodes
 Non palpable lymph nodes
 Chest/Lungs:
 Skin is brown, no lesions, no visible dilated
blood vessels
 Thorax is symmetrical and no deformity
 Symmetrical chest expansion
 (-) tenderness, palpable mass
 (-) crackles, bronchophony, egophony,
whispered pectoriloquy
 Normal and equal tactile fremitus, vesicular
breath sounds
 Cardio
 Apex beat at 5th ICS left midclavicular line
 Irregular beats
 Adynamic precordium
 (-) palpitatiion, lift, heave, murmurs and thrills

 Extremities
 Grossly normal extremities
 Full and equal pulses
 (-) cyanosis and discoloration
 (-) bruises and lesions
 Full range of motion
 With a thorough history and physical exam,
the obstetrician should be able to formulate a
clinical impression.

 This impression will then be confirmed

through appropriate laboratory examinations.
THANK YOU!