1. HISTORY & PHYSICAL EXAM IN OBGYN(0).ppt

History taking

1. HISTORY & PHYSICAL
EXAM IN OB/GYN
Dr Olana Terefa(MD, Lecturer)

2. What is Obstetrics?
The word obstetricsis derived from the
Latin obstetrix,meaning midwife.
The word also is connected with the
verb obstare—to stand by or in front of.
The rationale for this derivation is that
the midwife stood by or in front of the
parturient.

3. HISTORY & PHYSICAL EXAM
IN OB/GYN
COMPONENTS OF OBSTETRIC HISTORY:
Identification
Chief complaint (C/C)
Hx of present pregnancy (HPP)
Past Obstetric Hx
Past Gynecologic Hx
Past Medical & Surgical Hx
Personal & Social
Family Hx
Systemic Review

4. COMPONENTS OF OBSTETRIC
P/E
General Appearance (GA)
Vital Sign (V/S)
HEENT
Lympho-glandular system (LGS)
Respiratory System (RS)
Cardiovascular system (CVS)
ABDOMEN (GIT)
Genito –Urinary System (GUS)
Integumantary System
Musculoskeletal System (MSS)
Nervous System (NS)
SUMMARY OF Hx & P/E
ASSESSMENT/ or DIAGNOSIS /or IMPRESSION
DIFFERENTIAL DIAGNOSIS (DDx)
INVESTIGATIONS
TREATMENT PLAN

5. OBSTETRIC HISTORY
1. IDENTIFICATION:-Emphasize on
-Name
-Age: <18 yrs or > 35 yrs = > high risk group.
-Marital status:
=> Unmarried & unsupported are high risk group.
-Address, Religion, Ethnicity
-Occupation
-Date of admission, Ward, bed number
-Previous history of admission,
-How the patient was brought to the hospital
-Source of information, language of communication
-Source of referral
NB: Objective of identification:
To know/identify the patient
To identify risk factor for current pts compliant
To make follow up arrangements

6. 2. CHIEF COMPLAINT (c/c):
-Patients might have come for scheduled ANC follow up
or
-May have a specific complaint e.g. nausea and
Vomiting, Vaginal bleeding etc.
3. HISTORY OF PRESENT PREGNANCY (HPP):
It should include the following information:
Gravidity–all previous pregnancies
–Term live birth, still births, abortions, ectopic
pregnancy or hydatidiform mole.
Parity–Pregnancies that have extended beyond fetal
viability whether the fetus is delivered alive or dead.
> 28 weeks: -UK and Ethiopia
> 20 weeks for WHO
Abortion(s); number, induced or spontaneous

7. Hx OF PRESENT PREGNANCY (HPP)…
LNMP:-1
st
day of normal period. To be considered as reliable if:
-Menstrual cycle has been regular
-No use of hormonal contraceptives for at least 3 months prior
to LNMP or regular cycles
-If lactating, should have seen at least 3 regular cycles
Calculate the EDD: –40 weeks or 280 days after LMP
–5% of pregnant women deliver on this day.
Term pregnancy: 37 –42 completed weeks.
Preterm pregnancy: < 37 completed weeks.
Post term pregnancy: > 42 ›› ››
Naegle’s rule: LNMP –3 months + 7 days (for the European C.).
For the Ethiopian calendar:
EDD = LNMP + 9 months + 10 days if Pagume is not crossed, or
EDD = LNMP –3months + (5 or 4 days if Pagume is 5 or 6 days
respectively), If Pagume is passed or crossed.
Calculate gestational age in completed weeks and days.

8. HPP…
Quickening:-1
st
time the mother felt fetal movement or kick
-used to calculate the date of the pregnancy if LMP is unknown.
= > for Primigravidas: b/n 18 –20 weeks.
= > for Multigravidas: b/n 16 –18 weeks( because of experience)
ANC status should be documented & if not followed, the reason
should be sought.
Elaborate the chief complaint
Any complaints during the present pregnancy-eventful or
uneventful
Ask for danger signs: -Vaginal bleeding, leakage of liquor,
abdominal pain, fever, … etc.
Fetal movements decreased or increased? It is useful to assess
fetal well being.
Other negative and positive statements should be asked according
to the patient’s complaints e.g. Headache, blurring of vision,
epigastric pain or convulsion in hypertensive disorders of
pregnancy etc

9. 4. PAST OBSTETRIC HISTORY…
=> Document all previous pregnancies in a
chronological order.
Year of gestation, Length of gestation, birth
weight, fetal outcome, length of labor, fetal
presentation, mode of delivery,
Complications: -Ante partum, intrapartum &
post partum.
Important because most obstetric problems are
recurrent and have a chance of recurring in the
current pregnancy e.g. APH, PPH, PROM,
GDM, PIH, C/S, Ectopic pregnancy & abortion.

10. PAST OBSTETRIC Hx,
Summary
Order of
pregnan
cy
Antepar
tum
complic
ations
Length of
Gestation
Length
of labor
Mode of
Delivery
Birth
Outcome
Postpart
um
complica
tion
Child
alive
or not
1
st
2
nd

11. 5. PAST GYNECOLOGIC HISTORY
-Contraception –use of any form of
contraception, type and duration
Sexual history –including history of STD:
Assess risk of HIV / AIDS
History of gynecologic procedures including
history of female genital cutting (FGM).
History of previous gynecologic surgery or
procedure –e.g. prior uterine surgery;
hysterectomy, myomectomy, D&C, MVA,
E&C…
Menstrual history: age at menarche, interval
between periods, duration of flow, amount and
character of flow, degree of discomfort.

12. PAST GYNECOLOGIC HISTORY…
Normal menstrual cycles:
= > 1 –8 days of flow / 5 days on
average
= > 21–35 days cycle length / 28 days
on
average.
= > 10 –80ml /50ml on average
amount of
blood flow
= > Dark non-clotting blood.
Clotting of menstrual blood, increased
number of pads used and anemia

13. 6. PAST MEDICAL AND SURGICAL Hx:
Medical disorders may affect the outcome of
pregnancy and the physiological changes of
pregnancy may aggravate the medical disorder.
e.g. Diabetes mellitus, Hypertension,
Thyrotoxicosis or Hypothyroidism, Tb, etc
Previous blood transfusion –may be related to
hemolytic disease of the newborn.
Hypersensitivity to drugs should be asked.
History of maternal infection during pregnancy
should be asked –e.g. STD, rubella, malaria,
etc.
Previous hx of surgery: eg, appendectomy,
cholecystectomy, thyroidectomy ….etc

14. 7. PERSONAL & SOCIAL HISTORY ( +FAMILY
HISTORY)
Early childhood history, number of
siblings, whether parents and siblings
are alive or not. If dead, reason for
death should be mentioned to uncover
familial reasons.
Educational status
Habits –smoking, alcohol and drug use
may have a deleterious effect on
pregnancy.
e.g. fetal alcohol syndrome.
Occupation and family income –Low
socio economic status is associated with
pregnancy complication. e.g. pre-
eclampsia, preterm labor, PROM, etc.

15. 8. FAMILY HISTORY
Family history of –Diabetes mellitus,
Hypertension, Tuberculosis, Twinning,
Hereditary diseases, chromosomal
anomalies, allergies, and mental
disorders-running in the family.
9. SYSTEMIC REVIEW / FUNCTIONAL
ENQUIRY
A check list for the health professional
in all the systems

16. B. PHYSICAL EXAMINATION (P/E)
P/E should be conducted in an environment that is
aesthetically pleasing to the patient.
A female assistant (chaperone) should be present whenever
possible.
Adequate gowning and draping is necessary to avoid
embarrassment.
Warm instruments, reassurance and adequate lighting should
be used.
General physical examination covering all the systems should
be conducted thoroughly.
1.GENERAL APPEARANCE:
-Acutely or chronically sick looking, well looking,
-Mood of the patient,
-Body morphism (nutritional status)

17. PHYSICAL EXAMINATION (P/E)…
2. VITAL SIGNS:
Blood pressure: –should be measured in the sitting
position or 30 degree left lateral tilt to avoid supine
hypotension syndrome due to vena caval
compression. DBP is taken at the point of
disappearance (5
th
Korotkoff’s) point.
Pulse: 10 –15 beats / minute increase in pulse rate
during pregnancy.
RR: 1 –4 breathes / minute increase during
pregnancy
Temperature
Weight: -ideal body weight found by using Broca’s
formula = Height in cms –100
+/-20% this is the cut off point for the normal range.
Weight gain > 1Kg / wk is abnormal
Height < 150 cms is a risk for contracted pelvis (CPD)

18. 3. HEENT EXAMINATION
-Emphasize on head, ear, eye (conjunctiva,
sclera), nose and throat or teeth
4. LYMPHO-GLANDULAR SYSTEM (LGS):
-All superficial lymphatic system should be
evaluated.
-Glands:-Thyroid
-Breast:-detailed examination
-Nipple retraction:–should be treated
during pregnancy so that it will not interfere
with breast feeding.
5. RESPIRATORY SYSTEM / Chest –same as
non-pregnant.

19. 6. CARDIO-VASCULAR SYSTEM
Same as non –pregnant
-PMI may be deviated to the left.
-S3 gallop may be heard normally.
-Functional systolic murmur < III/VI
grade may be heard.

20. 7. ABDOMEN
a) Inspection:
Distension–site of distension, uniformity, shape
and peristalytic movement
Symmetry: symmetrical or asymmetrical -tilted
to the right or to the left
Linea nigra-midline hyperpigmentaion due to
increased Melanocyte Stimulating Hormone
(MSH) during pregnancy
Stria gravidarum –purplish mark on the
abdomen, thighs & breasts due to the distension.
(primigravida)
New Stria gravidarum are few in number, thick
and purplish to dark in color.
Old Stria gravidarum (Stria albicantes) are
whitish, much thinner and numerous in numbers
compared to the new ones. (previous Px)

21. 7. ABDOMEN…
Inspection…
Umbilicus -flat, inverted or everted.
Scars: -surgical or non-surgical
Surgical:
-sub umbilical midline or
-Pfannensteil -suprapubic transverse
scar
Distended veins
Flanks –full or not
Pulsatile mass

22. 7. ABDOMEN…
b. Palpation:
i. Superficial palpation-
Look for rigidity, tenderness, superficial
mass, characterizes mass, abdominal wall
defect.
ii. Deep Palpation
Look for mass, organomegally, tenderness
Characterize mass (size, organ, mobility,
tenderness, shape, and contour)
iii. Obstetric palpation:
Leopold I: –Fundal palpation.
-Has 2 purposes:
1) Determination of fundal height, and
2) What occupies the fundus?

23. OBSTETRIC PALPATION…
Leopold I: –Fundal palpation…
Fundal height (fh) measurement-
should be after correcting for
dextrorotation.
There are 2 methods of measuring the fh:
1. Finger method:
-below the umbilicus, 1 finger = 1 week
-Above the umbilicus, 1 finger = 2
weeks

24. OBSTETRIC PALPATION…
Body marks:
-Uterus at symphysis pubis = 12 weeks
-At the umbilicus = 20 weeks
-At Xiphisternum = 38 weeks
-Midways b/n symphysis & umbilicus =
16wks
-Midways b/n umbilicus & Xiphisternum
= 28wks

25. OBSTETRIC PALPATION…
2. Tape measurement:
Symphysis to fundal height measurement
in cms with tape meter.
At 18 –34 weeks of gestation, tape
measurement is accurate to +2 weeks of
actual Gestational age.
McDonald rule & Johnson formula for GA
& Fetal weight estimation.
What occupies the fundus?
Soft irregular bulky mass -the breech
Hard round ballotable mass –Head

26. OBSTETRIC PALPATION…
Leopold II: –Lateral palpation
Has 2 purposes: 1) To know the lie
2) To determine side of the back
1. Lie: -is the longitudinal axis of the fetus in
relation to the longitudinal axis of the mother.
-It can be longitudinal, transverse or oblique.
2. Side of the back –to auscultate the FHR on
that side.
FHR can be auscultated at 20 weeks by using
the De Lee /Pinard stethoscope or at 10 -12
weeks using Doppler Ultrasound.

27. OBSTETRIC PALPATION…
Leopold III –pelvic palpation
–It has three purposes; to know the
1) Presentation
2) Descent of presenting part.
3) Attitude of the fetal head.
Presentation:–is the part of the fetus that
occupies the lower uterine pole.
E.g. Cephalic, breech & shoulder
presentation
Descent is measured after identifying the
anterior shoulder with rule of 5
th
in fingers above
pelvic brim.
5/ 5
th
–floating

28. OBSTETRIC PALPATION…
Attitude: is the relationship of the fetal parts to
each other particularly the fetal head to its trunk.
-Cephalic prominence on the side of the back.
Extended attitude = > abnormal
Cephalic prominence opposite to the side of the
back
Flexed attitude = > normal
Military Attitude: -neither flexed nor extended
Leopold IV –Pawlik’s grip:–It has two
purposes.
To know the 1) Presentation and
2) Descent or mobility of the fetal
head
=> floating or fixed

29. 7. ABDOMEN…
c. Percussion:–Shifting & flank dullness and
fluid thrill –as in ascites & polyhydramnios
d. Auscultation: -FHB first heard at the 20
th
week –On the side of the back.
Below the umbilicus in cephalic
presentation
Above the umbilicus in breech presentation
At flanks in OP position

30. 8. GENITOURINARY SYSTEM
Pelvic assessment (PV Exam):
-Done at two times during pregnancy unless otherwise indicated
due to complications and in labor
1. Early –During the 1
st
trimester as early as possible.
Purposes: -To diagnose pregnancy
-To date pregnancy by measuring uterine size
-To diagnose pelvic problems like ovarian cyst and uterine
anomalies & Vaginal congenital anomalies like septum as early as
possible.
2. Late in pregnancy (>37 Weeks).
Purposes: -for soft tissues assessment
For pelvic assessment to diagnose contracted pelvis/ bony pelvis
assessment
= > to assess the pelvic inlet, mid cavity & outlet.

31. 9. INTEGUMANTARY SYSTEM…
INTEGUMANTARY SYSTEM : -as in
Gynecologic history
10. MUSCULOSKELETAL SYSTEM:
Extremities -Look for edema –pretibial, ankle
& pedal (dependent edema)
= > 80% of normal pregnant women can have
dependent leg edema.
Other areas to look for pathological (Non-
dependent edema.)
= > Facial edema.
= > Tightening of rings (finger)
= > Sacral edema
= > Abdominal wall edema

32. 11. NERVOUS SYSTEM (NS):
Nervous System: -seeGynecologic P/E
part
-Reflex
-Consciousness
-Gross neurological deficit
12. Summary of Hx & P/E
13. Assessment Or Diagnosis Or
Impression
14. Differential Diagnosis (DDx)
15. Investigations
16. Treatment plan

33. INTRODUCTION TO
GYNECOLOGY
What is Gynecology?
Gynecology, spelled gynaecology, is defined
by the Oxford English Dictionary as a
department of medical science which treats of
the functions and diseases peculiar to women.
The word was first used as such in the middle
of the 19th century. In 1867, gynecology
represented the physiology and pathology of
the non pregnant state.

34. GYNECOLOGIC Hx & P/E
COMPONENTS OF GYNECOLOGIC
HISTORY:
Identification
Chief complaint (C/C)
Hx of present illness (HPI)
Past Gynecologic Hx
Past Obstetric Hx
Past Medical & Surgical Hx
Personal & Social
Family Hx
Systemic Review

35. GYNECOLOGIC HISTORY
IDENTIFICATION: -same as obstetric history
CHIEF COMPLAINT(S):-same as obstetric history
Gynecologic patents may present with any one of the
following complaints:
E.g. -Cessation of menses.
-Vaginal bleeding
-Vaginal discharge
-Lower abdominal pain
-Pain during menstruation
-Mass protruding out of the introitus
(mass per vaginum)
-Urinary incontinence
-Ulcers on external genitalia
-Abdominal distension
-Hirsutism –abnormal hair growth pattern

36. HISTORY OF PRESENT ILLNESS (HPI)
Reproductive history-Gravidity, Parity, Abortions,
Ectopic pregnancy
Each complaint should be discussed in detail.
Each problem –where exactly is it occurring?
Date and time of onset
Aggravating or relieving factors
Duration when they occur, Example,
Abnormal uterine bleeding (AUB): -Describe
clearly onset, duration of flow, amount-indicated by
number of pads used per day, clotting of menstrual
blood. Describe relation of AUB to menstrual cycle &
LNMP.
LNMP should be included in the HPI??? Menstrual
history in detail can be included in the HPI or
elsewhere if not pertinent to the present complaints.

37. HPI…
Vaginal discharge:
-Color, odor, amount, Viscosity.
-Timing in relation to menstrual cycle
-Associated with abnormal vaginal bleeding-may
indicate malignancy
-Itching –indicates infection
Abdominal pain:–PQRST
-Location (position)
-Quality
-Radiation
-Severity
-Timing -intermittent, constant, etc
-Especially relationship to menstrual cycle
-Pain during menstruation could be primary or
secondary dysmenorrhea.

38. HPI…
Contraceptive history, sexual history and
menstrual history should be included in the HPI
if pertinent to the present complaints other wise
can be included in the past gynecologic history.
Negative –positive statements pertinent to the
presenting complaints should be discussed in
detail.
Menstrual history: -Age at menarche, interval
between periods, duration of flow, amount and
character of flow, degree of discomfort and age
at menopause.

39. HPI…
PAST GYNECOLOGIC HISTORY: -As in obstetrics
history
PAST OBSTETRIC HISTORY : -As in obstetrics history
PAST MEDICAL AND SURGICAL HISTORY: -As in
obstetrics history
PERSONAL & SOCIAL HISTORY: -As in obstetrics
history
FAMILY HISTORY: -As in obstetric history
SYSTEMIC REVIEW / FUNCTIONAL ENQUIRY :

40. GYNECOLOGIC PHYSICAL
EXAMINATION
A. GENERAL APPEARANCE: -as in
obstetrics
B. VITAL SIGNS: -as is done for any
patient
Weight: –obesity is a risk factor for
certain gynecologic illnesses: e.g.
Endometrial Ca, Ovarian Ca, Amenorrhea.
Height: –especially important in
postmenopausal patients to document
loss of height from osteoporosis and
vertebral fractures.
C. HEENT:-as in obstetrics

41. D. LYMPHOGLANDULAR SYSTEM:
Breast examination:
Inspection:-with patient’s hands pressing on
her hips and arms above the head respectively
-Symmetry, dimpling, peau-de-orange, nipple
retraction, ulceration & eczematous nipple
lesions should be documented
Palpation:–all four quadrants, axillary’s tail,
nipples area for discharge.
-Axillary, supraclavicular and cervical lymph
nodes should be palpated with detailed
description of a mass.

42. GYN P/E…
E. RS: -as in any other patient
F. CVS: -as in any other patient
G. ABDOMINAL EXAMINATION
-Inspection: –as usual as is done for any
patient.
-Auscultation:-Bruie over a mass &
bowel sound
-Palpation:-Superficial
-Deep

43. ABDOMINAL EXAMINATION…
Abdominal Mass: –Describe Size,
origin, consistency, mobility, tenderness
and contour
Size: -in weeks of pregnant uterus size
-12 weeks at symphysis pubis
-20 weeks at umbilicus
-38 weeks at xiphisternum
Origin:-pelvic -abdominal mass arising
from the pelvis or an abdomen can be
differentiated by identifying if one can go
below the mass in to the pelvic cavity or
not?

44. ABDOMINAL EXAMINATION…
Mobility: -fixation may indicate adhesions or
malignancy
Tenderness
Surface contour: -smooth, irregular or nodular
Check for Organomegally: –liver, spleen,
Kidneys.
Percussion:-Shifting dullness, fluid thrill to
detect ascites
Differentiation of a large ovarian tumor versus
ascites: -Large ovarian tumor has central
dullness with tympanicity at the flanks as
opposed to ascites with central tympanicity and

45. H. GENITOURINARY SYSTEM:
= > CVA and suprapubic tenderness
= > Pelvic Examination
Pelvic examination: –has 5 components
-Examination of external genitalia
-Speculum examination
-Digital vaginal examination
-Bimanual pelvic examination
and
-Rectovaginal examination

46. Pelvic Examination…
A. Examination of external genitalia:-
Inspection and palpation
-Pubic hair pattern: -Masculine-diamond shaped
-Feminine-inverted triangle.
-Infected hair follicles etc.
Skin of vulva, mons pubis and perineal area
inspected for dermatitis or discoloration
e.g. whitish discoloration in vulvar
dystrophies.
Ulcers or swelling E.g. sebaceous cysts or
tumors
Labia majora and minora:
Ulcers, swelling or tumors such as Condyloma
accuminata could be found.
Evidence of FGM -scarring etc.

47. Pelvic Examination…
Urethral orifice: -should be of the same
color as surrounding
-Milk for discharge
-Urethral caruncle or tumor if any
Area of Bartholin’s gland: -at 5 & 7
o’clock position
-Inspection & palpation for swelling and
tenderness
Discharge or bleeding from the introitus –
should be noted.

48. Pelvic Examination…
Hymen: -Unruptured, many forms –annular,
crescentic, or fimbriated.
-Imperforated hymen is pathological
-Ruptured -especially after the birth of many
children
-remnants of ruptured hymen is called
carunculae myrtiformis.
-Examination of hymen is important in cases
of sexual assault.
-Check perineal support: –open the labia with
2 fingers and ask patient to strain to document
genital prolapse.

49. Pelvic Examination…
B. Speculum examination
-Speculum –Dampened with warm water but
not lubricants
-Types: -Cusco’s (Graves): bivalve
speculum.
-Sims speculum: monovalve
speculum
-Choice of several sizes depending on age
etc.
The following should be documented.
Vagina: -Color-pink, whitened, inflamed
-Congenital anomalies like vaginal septum.
-Fornices: -formed, flattened, bulging
especially posterior fornix

50. Pelvic Examination…
Cervix: -Os: –Nulliparous –pinpointed.
-Multiparious –slit-like
-Erosions, scars, lacerations, ulcer,
mass,
-Nabothian cysts, discharge or bleeding
-Effacement, dilatation,
-Any mass or polyp from Os or from the surface
Papanicoulau’s (Pap) smear should be taken at
this time from the exocervix and endocervix
using Ayre’s spatula and an endocervical brush
respectively.

51. SPECULUM

52. Pelvic Examination…
C. Digital vaginal examination: -Note the following
The patient should have voided just prior to
examination to avoid difficulty in examining the uterus
and adnexa by the distended bladder.
Vaginal: -masses, tenderness or stenosis
Fornices: -formed or obliterated
-Bulging especially posterior fornix (cul-de-sac)
-Tenderness
Cervix: –consistency: –Tip of nose –normal
-Hard in malignancies.
-Excitation (motion) tenderness
-Effacement, position & dilation

53. Pelvic Examination…
D. Bimanual pelvic examination:
-To delineate the uterus and adnexa between
the 2 fingers in the vagina and the palm of the
other hand on the lower abdominal wall.
-Note the following:
a. Cervix: -3-4 cms in diameter/length, round,
tip of the nose consistency
-External os is usually closed
-Smooth surface normally
-Can be moved 2-4 cms in any direction
without discomfort.

54. Pelvic Examination…
b. Uterus: -Dimensions of normal uterus =
9 cms in length, 7 cms in width, 70 -90
grams in weight.
Assess the following regarding the uterus:
Position: –Anteverted –normally
-Ante flexed –body of the uterus flexed
at cervix
-Retroverted & retroflexed normally in
20% of cases
Tenderness: –normally non-tender
organ

55. Pelvic Examination…
b. Uterus…
Mobility: –mobile in all directions normally.
Fixation: –may be due to cancer /
neoplasia or inflammation.
Size: –described in pregnant uterus size;
in weeks
Surface contour: -smooth normally
Consistency: –firm normally

56. Pelvic Examination…
c. Adnexa: -Refers to the –Tubes, ovaries,
broad ligament and parametrium
Ovaries: -3cm x2cm x l cms in size.
= > May be palpable in thin women with
soft abdominal walls.
= > Tender normally.
Tubes diameter = 7 mms at its greatest
diameter
Description of adnexal mass: in a similar
way to uterine mass

57. Bimanual pelivc examination

58. Pelvic Examination…
E. Recto vaginal examination:
Itis performed with the index finger in the
vagina and the middle finger in the rectum.
The structures that lie in between the two
fingers include the rectovaginal septum or
structures that may dissect it.
A cul-de-sac abscess may dissect the septum
and be detected on rectovaginal exam.
A cervical carcinoma may also infiltrate the
septum.
Rectovaginal exam is also useful in
differentiating a rectocele from an enterocele.
An enterocele is felt descending in between the
two fingers on straining.

59. Recto-vaginal Examination

60. I.INTEGUMANTARY SYSTEM:
The skin is examined for texture, dryness
or moisture, temperature, purpura, rashes,
urticaria, ulcers and hypo or
hyperpigmentations.
The hair is examined for sparseness,
baldness, alopecia and texture.
The color, shape (clubbing, spooning),
texture, capillary refill and presence of
splinter hemorrhages are noted on
examining the nails.
Presence or absence of Hirsutism and its
extent is noted.

61. J. MUSKULOSKELETAL SYSTEM :
Presence of muscle tenderness or spasm
is noted.
The spine is examined for tenderness on
percussion or pressure, kyphosis,
scoliosis, lordosis, malformation, gibbus
and limitation of movement.
Joints are evaluated for swelling,
tenderness, redness, heat, crepitus,
limitation of movement on active or
passive motions, effusion, masses,
dislocation and deformity.
On the examination of bones mention is
made of fractures, deformity, tumor,
periosteal thickening and tenderness.

62. K. NERVOUS SYSTEM :
It includes assessment of:
-Central as well as peripheral nervous system
functions.
Mental status: -orientation to time, place &
person.
-long and short term memory
-level of consciousness
-intelligence, mood, attention, speech,
hallucinations and delusions
-level of education & cooperation with the
examiner.
The 12 cranial nerves for their specific
functions

63. NERVOUS SYSTEM…
Motor functions (muscle volume, tone, power,
fasciculation & involuntary movements).
Sensory functions:
-Superficial: -light touch, pain, and
temperature.
-Deep: -position, deep pain, vibration,
Romberg’s sign & ataxia gait.
Superficial and Deep tendon reflexes:
-Superficial:-includes corneal, abdominal,
cremasteric and plantar reflexes.
-Deep:-biceps, triceps, supinators, patellar
and ankle reflexes.
Meningeal signs (nuchal rigidity, Kerning’s sign
and Brudzinski’s sign).

64. L. Summary of Hx & P/E
M. Assessment / Diagnosis
N. Differential diagnosis
O. Investigations
P. Treatment plan
……………………….. The End !

65. Ex. This is a G 5, P 2, Ab1, Ectop 1
means,
she had 4 past pregnancies
-2 delivered
-1 aborted
-1 was ectopic pregnancy
and she is currently pregnant for the 5th
time

66. 7/11/2024
Ex LNMP 10/1/10
EDD will be on ….
LNMP 24/3/010
EDD will be on ….