• Clinical science

OB/GYN: history and physical examination

Summary

The process of taking a history and performing a physical examination (H&P) in OB/GYN patients presents unique challenges. Because of the intimate aspect of an OB/GYN examination, it is important to establish trust and a private and relaxing setting for the patient. This article provides an overview of the possible content of the H&P of the OB/GYN patient. Depending on the patient's symptoms, additional and/or more targeted questions may also be relevant. See the medical history and physical examination articles for more information on general clinical examination.

Gynecologic and obstetric history

General principles

  • A key difference in OB/GYN history taking is the focus on the menstrual/menopausal history and sexual history.
  • Patients may be hesitant to disclose certain aspects of their gynecologic history because of the sensitive nature of the topic. In some cases, it may be due to cultural differences or even a history of abuse.
  • Be empathetic and try to create a comfortable environment for each of your patients, since it will encourage them to discuss matters more openly with you.
  • If you feel that the patient is uncomfortable talking about their gynecologic history, start with a social or family history in order to establish rapport with the patient.

Gynecologic history

Chief concern and history of present illness

  • Begin with a brief summary of the patient's age, parity, date of last menstrual period (LMP), and any current concerns the patient may have.
  • Common chief concerns in gynecology
    • Vaginal bleeding should be evaluated based on the following:
    • Vaginal discharge should be evaluated based on the following:
      • Color (e.g., bloody, brown, yellow, green, or gray)
      • Consistency (e.g., frothy, curd-like)
      • Amount
      • Smell (e.g., fishy)
    • Pruritic and/or erythematous vagina
    • Abdominal or pelvic pain, that can be described using the SOCRATES mnemonic:
      • Site
      • Onset
      • Character
      • Radiation
      • Associations
      • Time course
      • Exacerbating and relieving factors
      • Severity

To evaluate abdominal/pelvic pain, use the SOCRATES mnemonic: Site, Onset, Character, Radiation, Associations, Time course, Exacerbating and relieving factors, Severity.

Menstrual history

Menopausal history (if applicable)

Past gynecologic history

Past obstetric history

Sexual history

  • Opening the discussion
    • Discussing a patient's health is often a sensitive matter. It is important to encourage the patient to be as descriptive as possible while remaining sensitive to the fact that they are sharing very private details of their life. Always remain empathetic and open to discussion.
    • If the patient seems hesitant, explain to them that this information is vital for forming an overall picture of their health and that it is as important as other aspects of their physical and mental health.
  • Current/past sexual partners
    • Discussing the patient's current/past sexual partners is an important part of taking a patient's sexual history.
    • The following questions can be used:
      • Are you currently sexually active? If no, have you ever been sexually active?
      • In recent months, how many sex partners have you had? In the past 12 months, how many sex partners have you had?
      • Are your sex partners men, women, or both?”: If a patient answers “both,” repeat the first two questions for each specific gender.
  • Current/past sex practices
    • It is necessary to ask about the patient's sexual practices to understand their risk for sexually transmitted infections (STIs), the need for testing, and to guide a discussion regarding risk-reduction strategies.
    • Example: “I am going to ask you a few questions to better understand if you are at risk for STIs. What kind of sexual contact do you usually engage in (genital/oral/anal)?
  • Current/past contraception methods use
    • This part of sexual history is particularly important since the use of barrier contraceptive methods can significantly reduce one's risk of STIs. Therefore, collecting this information can be very helpful in terms of assessing one's risk of developing an STI.
    • Example: “Do you and your partner(s) use any contraceptive methods or practice any form of birth control?
      • If no, ask them why not.
      • If yes, ask them which method of contraception they use and with what frequency.
    • If the patient is sexually active, be sure to ask them if they are trying to conceive. If so, ask (how long they've been trying and) if they are experiencing any difficulties.
    • Always give the patient the chance to ask questions about their sexual health including different types of contraception, their indications, contraindications, as well as the potential for STI transmission , and the benefit of using barrier contraceptive methods as an STI prophylaxis method.
  • History of STIs
    • A history of STIs should cover the patient's previous diagnoses and/or treatments of STIs, the presence of recurrent symptoms, as well as past STI testing results.
    • The following questions can be used:
      • Have you ever been diagnosed with an STI? When? How were you treated?
      • Have you ever been tested for HIV, or other STIs? Would you like to be tested?
      • Has your current partner or any former partner ever been diagnosed or treated for an STI? Were you tested for the same STI(s)? If yes, when were you tested? What was the diagnosis? How was it treated?
  • History of postcoital vaginal bleeding
  • History of sexual dysfunction (e.g., dyspareunia, low libido)
  • History of sexual abuse

The 5 P's of a sexual history include Partners, Practices, Protection from STIs, Past history of STIs, and Prevention of pregnancy.

Medications and allergies

  • Prescribed drugs
  • Over-the-counter drugs
  • Herbal remedies
  • Allergies to drugs or environmental factors and reaction to each allergen

Family history

Social history

  • Relationship status
  • Socioeconomic status
  • Occupation
  • Drug and alcohol use

Review of systems

  • See medical history for more information on the complete review of systems.
  • In the OB/GYN examination, a particular emphasis should be placed on the:
    • Urogenital system (e.g., dysuria, hesitancy, urgency, incontinence, change in bowel habits, rectal bleeding)
    • Abdomen (e.g., abdominal/pelvic pain)
    • Breasts
  • For post/perimenopausal woman, it is important to ask about menopausal symptoms (e.g., hot flashes/night sweats, vaginal dryness, abnormal bleeding, irritability, depression, mood changes).

If you feel that the patient is not comfortable talking about their gynecologic history, start with social/family history in order to establish rapport with the patient.

Obstetric history

Obstetric history taking varies based on the setting (normal prenatal checkup vs. patient presenting with a concern).

Past obstetric history (GTPAL system)

GTPAL is an acronym used by doctors and nurses to sum up the obstetric history of a woman: Gravida, Term births, Preterm births, Abortions, Living children.

Current pregnancy

If the mother is not aware of previous perinatal complications, try asking her how soon she went home with the baby after the delivery.

Gynecologic examination

Preliminary considerations

Because of the sensitive nature of this physical examination, patients are often anxious, which can further complicate the exam itself. It is important to make sure the patient feels comfortable prior to proceeding.

  • Always begin by explaining the procedure, the tools being used (e.g., speculum), why the examination is being done, and what you are looking for.
  • Ask the patient how they feel and give them a chance to clarify any concerns they have with you.
  • Let the patient know that they are still in control throughout the process. Assure them that you will not proceed if they are in pain or distress. Asking questions such as, “Does this hurt too much?” or “Are you alright with me proceeding?” will give the patient the feeling that they can stop the process if needed, and help them relax.

Instruments and equipment

  • Gynecologic exam: gloves, lubricant, vaginal speculum , cervicovaginal swab
  • Obstetric exam: measuring tape, Pinard stethoscope or doppler transducer, ultrasound gel

Gynecologic exam

  • Breast examination: check for any abnormalities of the breasts (e.g., skin changes, breast masses, nipple discharge)
  • Pelvic exam
    • External genital exam: Check for any abnormalities of the vulva and labia (e.g., swelling, irritation, ulcers).
    • Internal genital exam: includes the sterile speculum exam, cervicovaginal swab
    • Pap smear: See Pap smear in the cervical cancer article.
    • Bimanual pelvic exam: The physician inserts two fingers of one hand into the vagina while simultaneously pressing on the abdomen with the other hand, allowing both the uterus and adnexa (e.g., their localization, size, tenderness during manipulation, presence of masses) to be examined.
    • Rectovaginal pelvic exam: allows for the palpation of the rectovaginal septum in patients with suspected pelvic masses (e.g., colorectal cancer)
  • See physical examination and diagnostic procedures in gynecology for more information.

Obstetric examination

See prenatal care and childbirth for more information.