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General Physical Examination
The order of the examination presented here assumes the woman is sitting up to begin the examination. This description proceeds from head to toe, rather than by system.
1. Physical measurements. Obtain and review height, weight, blood pressure, pulse, and temperature (if indicated) before performing the physical examination. Height and weight are most useful when converted to the body mass index (BMI) using Table 6-1. Both BMI and blood pressure should be considered screening tools (see Chapter 7 for further discussion).
2. General appearance. Observe the woman for posture; striking or obvious characteristics or limitations; general emotional state; and appropriateness of dress, speech pattern, and social interaction during the visit.
3. Eyes, ears, nose, and throat. Inspect the physical health of the eyes, nose, and ears. Examination of the ears with the otoscope and examination of the eyes with the ophthalmoscope may be performed as indicated. The oropharynx examination includes inspection of the lips, teeth, and gums for dental health, and visualization of the oral cavity for mucosal color, lesions, and tonsillar edema or exudates.
4. Neck. Note range of motion and palpate lymph nodes in the neck and clavicular area.
5. Thyroid. Palpate the gland and isthmus.
6. Chest and lungs. Auscultate the posterior, lateral, and anterior lobes.
7. Spine. Palpate the vertebral column, and inspect the skin.
8. Kidneys. Check costovertebral tenderness.
9. Reflexes. Elicit patellar and additional reflexes as indicated.
10. Peripheral circulation and varicosities. Inspect legs and feet.
The woman then reclines and the examination continues:
11. Heart. Auscultate.
12. Breasts and axillary lymph nodes. See the next section.
13. Abdomen. Inspect the skin, palpate superficially and deeply in all quadrants, and palpate inguinal lymph nodes.
Reason the woman is seeking care (chief concern)
History of present illness/concern (see Box 6-2)
General medical history
• Current health conditions
• Previous serious illnesses
• Past hospitalizations
• Prior surgical procedures
• Immunization status
Mental health history
• Diagnoses and treatment
• History of self-harm practices and/or suicidal or homicidal thoughts
• Current concerns (depression screening)
Medications and allergies
• Current medications
• Over-the-counter (OTC) medications, including vitamins and complementary therapies
• Medication and other allergies
Substance use
• Alcohol
• Tobacco
• Cannabis
• Illegal drugs
• Misuse of OTC or prescribed medications
Family health history
• Illnesses and causes of death of first-degree relatives
• Congenital malformations and unexplained intellectual and developmental disabilities
Social history
• Education
• Hobbies
• Long-term life plans
• Partner(s)
• Living companions (children, family, roommates)
• Support system
Occupation and finances
• Current employment
• Occupational safety
• Military service
• Financial security
Safety
• Personal
• Home
• Community
• Sexual (current and historical)
Personal habits
• Health maintenance: exercise, sleep, nutrition, hydration
• Ongoing health maintenance
Menstrual history
• Age at menarche
• Date of last normal menstrual period (LMP)
• Cycle length, duration, and flow
• Any menstrual irregularities or symptoms associated with menses
Pregnancy history
• Gravida and para (see Box 6-4)
• Course of pregnancies: date, duration, type of birth, complications (pregnancy, birth, and postpartum), newborn’s sex and weight, and whether the child is currently alive and well
• For abortions (induced or spontaneous), ectopic pregnancies, blighted ovum, and molar pregnancies: gestational age, management, and complications
History of vaginal and sexually transmitted infections
• Previous vaginal infections and sexually transmitted infections
• Treatments received, frequency of infections, and complications
Genital hygiene
• Vaginal or rectal douching frequency, medication or solutions used, reasons for douching
• Hair maintenance
• Piercings
• Other products: creams, lubricants, specialty soaps, scented pads or tampons
Gynecologic procedures and surgeries
• Type of procedure or surgery, date, indication, complications, and outcome
Urologic and rectal health
• Occurrence and frequency of infections
• Urinary or bowel incontinence
• Other abnormal symptoms
Cervical cancer screening
• Date of last testing
• History of an abnormal result, and if so, follow-up and results since then
Sexual health
• Sexual orientation and gender identity
• Current sexual relationship(s): number of partners (current, in the past 6 months, and lifetime), sexual practices, safer sex practices
• Sexual satisfaction and orgasm
• Types of intercourse: oral, anal, vaginal, other
• Pain with sex
• Sexual concerns
Contraceptive use
• Present contraceptive method: type, duration used, satisfaction, side effects, and consistency of use
• Previous contraceptive use: method(s), duration of use, satisfaction, side effects, and reasons for discontinuing
Abnormal symptoms
• Pelvic pain, bleeding unrelated to menstruation, and other symptoms
• ravida or pregnancy: the total number of pregnancies the woman has had (this number should total the TPAL numbers)
• Term births: those occurring from 37 to 42 weeks’ gestation
• Preterm births: those occurring after the point of viability, which is usually interpreted as gestational age greater than 20 weeks and less than 37 weeks and/or fetal weight greater than 500 gm
• Abortions: spontaneous and induced prior to 20 weeks’ gestation
• Living children
