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
Gynecologic History
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General Item
Chief Complaint
Present Medical History
Past Medical History
Menstruation History
Marriage History
Social History
Family History
Gynecologic Physical Examination
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General exam
Abdominal exam
Pelvic exam-- Gynecology examination
Assistant Checkup
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Ordinary test
Special test
Physical Examination
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Symptoms
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General check up
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Abdomen examination
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Pelvic examination –Gynecology exam
General Item
Name, Gender, age, nationality, marriage,
occupation, hometown
Address, time of hospitalization, history collecting
time, history provider
Chief Complaint
The main symptoms or The duration of symptoms
（Professional 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
History of Present Illness
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Chronology of chief complaint from when the patient first
felt well until the present
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Detailed description of the chief complaint
--occur, evolution, diagnosis and treatment
procedures
History of Present Illness
Pain
Bleeding
• Location
• Onset and Duration
• Timing (onset, duration and frequency)
• Constant or Intermittent
• Quality (characteristics)
• Character
• Quantity or Severity
• Intensity
• Setting
• Alleviating or Precipitating factors
History of Present Illness
Vaginal Discharge
• Duration
• Characteristics
• Associated Symptoms
• Temporally Related Events
Past Medical History
• Medical illnesses (childhood and adult)
• Immunizations
• Surgical history
• Infectious diseases history
• Medications
• Allergies
• blood transfusion history
Menstruation History
5
12
50
28
• 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.
Marriage History
• 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
Personal Information History
Birth place, previous location
bad habits for cigarette and alcohol
Family History
Parents
cousins，sibling
Health conditions
children
• Any inheritable disorders
• Special attention to breast, ovarian and colon cancer
• Osteoporosis, heart disease and menopause
Obstetric History
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
Abdominal exam
• Inspection
• Ascultation
• Palpation
• Percussion
Discussion
1
Please write a complaint according to the following
information:
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Female patient, 42 years old, complaint in recent 1 years
by the increased amount of menses, accompanying a
backache with fatigue
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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:
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At the age of 28, amenorrhea for 2 months,
irregular vaginal bleeding
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40 years old, the vulva pruritus, leucorrhea is abnormal
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At the age of 26, 7+ months of pregnancy, vaginal bleeding
Medical history collecting and writing
Pelvic examination
Basic Requirements of the Pelvic Examination
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Check carefully, gentle movement
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Urine evacuated before check ( urine preserved for checkup )
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Replace the one-time pad
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Bladder lithotomy position
Q: To avoid the menstrual period, what should you do before
check, if check is must while bleeding?
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Male doctor to check best with female physician presence to
avoid unnecessary misunderstanding
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
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Speculum forbidden without
agreement by virgin
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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
Gynecological examination evaluation standard ( out of
100 points )
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 )
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 20 points )
The end
Thank you !