Clinical Approach to the Patient

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Chapter 2 Clinical Approach to the Patient

Joseph C. Gambone

As is the case in most areas of medicine, a careful history and physical examination should form the basis for patient evaluation and clinical management in obstetrics and gynecology. This chapter outlines the essential details of the clinical approach to, and evaluation of, the obstetric and gynecologic patient. Pediatric and adolescent patients, the geriatric patient, and women with disabilities all have unique gynecologic and reproductive needs, and this chapter concludes with information about their evaluation and management.

image Obstetric and Gynecologic Evaluation

In few areas of medicine is it necessary to be more sensitive to the emotional and psychological needs of the patient than in obstetrics and gynecology. By their very nature, the history and physical examination may cause embarrassment to some patients. The members of the medical care team are individually and collectively responsible for ensuring that each patient’s privacy and modesty are respected while providing the highest level of medical care. Box 2-1 lists the appropriate steps for the clinical approach to the patient.

BOX 2-1 Approach to the Patient

The doctor should always:

• Knock before entering the patient’s room.
• Identify himself or herself.
• Meet the patient initially when she is fully dressed, if possible.
• Address the patient courteously and respectfully.
• Respect the patient’s privacy and modesty during the interview and examination.
• Ensure cleanliness, good grooming, and good manners in all patient encounters.
• Beware that a casual and familiar approach is not acceptable to all patients; it is generally best to avoid addressing an adult patient by her first name.
• Maintain the privacy of the patient’s medical information and records.
• Be mindful and respectful of any cultural preferences.

Although a casual and familiar approach may be acceptable to many younger patients, it may offend others and be quite inappropriate for many older patients. Different circumstances with the same patient may dictate different levels of formality. Entrance to the patient’s room should be announced by a knock and spoken identification. A personal introduction with the stated reason for the visit should occur before any questions are asked or an examination is begun. The placement of the examination table should always be in a position that maximizes privacy for the patient as other health-care professionals enter the room. Finally, any appropriate cultural beliefs and preferences for care and treatment should be recognized and respected.

image Obstetric History

A complete history must be recorded at the time of the prepregnancy evaluation or at the initial antenatal visit. Several detailed standardized forms are available, but this should not negate the need for a detailed chronologic history taken personally by the physician who will be caring for the patient throughout her pregnancy. While taking the history, major opportunities will usually arise to provide counseling and explanations that serve to establish rapport and a supportive patient–physician encounter.

PREVIOUS PREGNANCIES

Each prior pregnancy should be reviewed in chronologic order and the following information recorded:

1. Date of delivery (or pregnancy termination)
2. Location of delivery (or pregnancy termination)
3. Duration of gestation (recorded in weeks). When correlated with birth weight, this information allows an assessment of fetal growth patterns. The gestational age of any spontaneous abortion is of importance in any subsequent pregnancy.
4. Type of delivery (or method of terminating pregnancy). This information is important for planning the method of delivery in the present pregnancy. A difficult forceps delivery or a cesarean section may require a personal review of the labor and delivery records.
5. Duration of labor (recorded in hours). This may alert the physician to the possibility of an unusually long or short labor.
6. Type of anesthesia. Any complications of anesthesia should be noted.
7. Maternal complications. Urinary tract infections, vaginal bleeding, hypertension, and postpartum complications may be repetitive; such knowledge is helpful in anticipating and preventing problems with the present pregnancy.
8. Newborn weight (in grams or pounds and ounces). This information may give indications of gestational diabetes, fetal growth problems, shoulder dystocia, or cephalopelvic disproportion.
9. Newborn gender. This may provide insight into patient and family expectations and may indicate certain genetic risk factors.
10. Fetal and neonatal complications. Certain questions should be asked to elicit any problems and to determine the need to obtain further information. Inquiry should be made as to whether the baby had any problems after it was born, whether the baby breathed and cried right away, and whether the baby left the hospital with the mother.

MENSTRUAL HISTORY

A good menstrual history is essential because it is the determinant for establishing the expected date of confinement (EDC). A modification of Nägele’s rule for establishing the EDC is to add 9 months and 7 days to the first day of the last normal menstrual period (LMP). For example:

LMP: July 20, 2008

EDC: April 27, 2009

This calculation assumes a normal 28-day cycle, and adjustments must be made for longer or shorter cycles. Any bleeding or spotting since the last normal menstrual period should be reviewed in detail and taken into account when calculating an EDC.

CONTRACEPTIVE HISTORY

This information is important for risk assessment. Oral contraceptives taken during early pregnancy have been associated with birth defects, and retained intrauterine devices (IUDs) can cause early pregnancy loss, infection, and premature delivery.

MEDICAL HISTORY

The importance of a good medical history cannot be overemphasized. In addition to common disorders, such as diabetes mellitus, hypertension, and renal disease, which are known to affect pregnancy outcome, all serious medical conditions should be recorded.

SURGICAL HISTORY

Each surgical procedure should be recorded chronologically, including date, hospital, surgeon, and complications. Trauma must also be listed (e.g., a fractured pelvis may result in diminished pelvic capacity).

SOCIAL HISTORY

Habits such as smoking, alcohol use, and other substance abuse are important factors that must be recorded and managed appropriately. The patient’s contact or exposure to domesticated animals, particularly cats (which carry a risk for toxoplasmosis), is important.

The patient’s type of work and lifestyle may affect the pregnancy. Exposure to solvents (carbon tetrachloride) or insulators (polychlorobromine compounds) in the workplace may lead to teratogenesis or hepatic toxicity.

image Obstetric Physical Examination

GENERAL PHYSICAL EXAMINATION

This procedure must be systematic and thorough and performed as early as possible in the prenatal period. A complete physical examination provides an opportunity to detect previously unrecognized abnormalities. Normal baseline levels must also be established, particularly those of weight, blood pressure, funduscopic (retina) appearance, and cardiac status.

PELVIC EXAMINATION

The initial pelvic examination should be done early in the prenatal period and should include the following: (1) inspection of the external genitalia, vagina, and cervix; (2) collection of cytologic specimens from the ectocervix and superficial endocervical canal; and (3) palpation of the cervix, uterus, and adnexa. The initial estimate of gestational age by uterine size becomes less accurate as pregnancy progresses. Rectal and rectovaginal examinations are also important aspects of this initial pelvic evaluation.

CLINICAL PELVIMETRY

This assessment is carried out following the bimanual pelvic examination and before the rectal examination. It is important that clinical pelvimetry be carried out systematically. The details of clinical pelvimetry are described in Chapter 8.

image Diagnosis of Pregnancy

The diagnosis of pregnancy and its location, based on physical signs and examination alone, may be quite challenging during the early weeks of amenorrhea. Urine pregnancy tests done in the office are reliable a few days after the first missed period, and office ultrasonography is used increasingly as a routine.

SYMPTOMS OF PREGNANCY

The most common symptoms in the early months of pregnancy are amenorrhea, urinary frequency, breast engorgement, nausea, tiredness, and easy fatigability. Amenorrhea in a previously normally menstruating, sexually active woman should be considered to be caused by pregnancy until proved otherwise. Urinary frequency is most likely caused by the pressure of the enlarged uterus on the bladder.

SIGNS OF PREGNANCY

The signs of pregnancy may be divided into presumptive, probable, and positive.

Presumptive Signs

The presumptive signs are primarily those associated with skin and mucous membrane changes. Discoloration and cyanosis of the vulva, vagina, and cervix are related to the generalized engorgement of the pelvic organs and are, therefore, nonspecific. The dark discoloration of the vulva and vaginal walls is known as Chadwick’s sign. Pigmentation of the skin and abdominal striae are nonspecific and unreliable signs. The most common sites for pigmentation are the midline of the lower abdomen (linea nigra), over the bridge of the nose, and under the eyes. The latter is called chloasma or the mask of pregnancy. Chloasma is also an occasional side effect of oral contraceptives.

Probable Signs

The probable signs of pregnancy are those mainly related to the detectable physical changes in the uterus. During early pregnancy, the uterus changes in size, shape, and consistency. Early uterine enlargement tends to be in the anteroposterior diameter so that the uterus becomes globular. In addition, because of asymmetric implantation of the ovum, one cornua of the uterus may enlarge slightly (Piskacek’s sign). Uterine consistency becomes softer, and it may be possible to palpate or to compress the connection between the cervix and fundus. This change is referred to as Hegar’s sign. The cervix also begins to soften early in pregnancy.

Positive Signs

The positive signs of pregnancy include the detection of a fetal heartbeat and the recognition of fetal movements. Modern Doppler techniques for detecting the fetal heartbeat may be successful as early as 9 weeks of gestation and are nearly always positive by 12 weeks. Fetal heart tones can usually be detected with a stethoscope between 16 and 20 weeks. The multiparous woman generally recognizes fetal movements between 15 and 17 weeks, whereas the primigravida usually does not recognize fetal movements until 18 to 20 weeks.

LABORATORY TESTS FOR PREGNANCY

Pregnancy Tests

Tests to detect pregnancy have revolutionized early diagnosis. Although they are considered a probable sign of pregnancy, the accuracy of these tests is very good. All commonly used methods depend on the detection of human chorionic gonadotropin (hCG) or its β subunit in urine or serum. Depending on the specific sensitivity of the test, pregnancy may be suspected even before a missed menstrual period.

Diagnostic Ultrasonography

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