GUIDELINES FOR COMPLETE HEALTH HISTORY AND PHYSICAL EXAMINATION

IDENTIFICATION Date and time of arrival to hospital Name: Age: Sex: Tribe: Marital status: Occupation: Religion: Address:

PRESENTING COMPLAINT: State in which patient came and not the diagnosis. Also state duration ---HISTORY OF PRESENTING COMPLAINT Onset: when did it develop i.e. duration of this symptom Character : Quality of symptoms (fully describe the symptoms):

Quantity of symptoms: assess severity:

How did the symptom progress over time: i.e periodicity

Associated symptoms:

Contributing factors Alleviated by: Aggravated by: If other symptoms exist, summarize this below

PAST HISTORY A] MEDICAL HISTORY Hospitalizations + other major adult and childhood illnesses What Surgical history What Drug Psychosocial history Occupational history: Marital status for how many years: Living circumstances and with who: Smoking and alcohol history: Home help: Social support: Gynecologic and obstetrics history Drug history Dose Frequency Duration When Which hospital How diagnosed When Which hospital How diagnosed

Last menstrual Date of the first day of the last period period Length of period Number of days the period lasts

Amount of bleeding Regularity of periods Erratic bleeding Pain Pregnancies Infertility Contraception Lifestyle
B] FAMILY HISTORY

How heavy the bleeding is each month (light, normal or heavy). Any episodes of flooding or passed clots Number of days between each period. Is the pattern regular or irregular? Bleeding between periods or after intercourse Association with menstruation. Does the pain precede or occur during the period? Record any births, miscarriages or abortions Is the patient trying to become pregnant? Record current and previous methods. Note that the patient's partner may have had a vasectomy or she may be in a same sex relationship Ask about weight, dieting and exercise

Age and cause of death or diagnosis of chronic conditions amongst the parents, siblings and children REVIEW OF SYSTEMS Cardiovascular system Chest discomfort/pain Breathlessness Palpitations Syncope/dizziness Oedema Respiratory system Breathlessness

Pain

Midline or lateralized: chest, abdomen or pelvis Localized or generalized

Abdominal distension

Upper gastrointestinal Xerostomia Halitosis Dry mouth Bad breath due to gingival, dental or pharyngeal infection Painful lips, tongue Pain at the angles of and mouth the mouth and buccal mucosa Dysgeusia Altered taste sensation Cacageusia Foul taste sensation, e.g. rotting food Globus Sensation of a lump in the throat Odynophagia Pain on swallowing Heartburn Burning retrosternal discomfort radiating upward Water brash Sudden appearance of excessive saliva in the

Cough Sputum Haemoptysis Gastrointestinal system General Anorexia Weight loss Loss of appetite Significant >3 kg in 6 months

mouth Dyspepsia Non-specific epigastric discomfort - 'indigestion' Early satiety Premature fullness on eating Nausea Feeling sick Haematemesis Vomiting fresh or altered blood Hiccups Persistent hiccups suggest diaphragmatic disorder Lower gastrointestinal Wind and flatulence Excessive, offensive flatus Bloating Uncomfortable distension Altered bowel habit Diarrhoea Abnormally soft stools and/or frequent defecation Constipation Abnormally firm stools and/or infrequent defecation Steatorrhoea Fatty stools, pale, greasy, difficult to flush Haematochezia Rectal bleeding Anismus/dyschezia Difficulty emptying the rectum despite prolonged straining Tenesmus Persistent urge to empty the rectum with the feeling of incomplete evacuation Melaena Black, tarry stools indicating bleeding from the upper GI tract

Cognitive disturbance: dysarthria, dysphasia, Memory Episodes of loss of consciousness Vision Hearing Speech, swallowing Arms, handwriting Legs, walking Involuntary movements Bladder, bowel function Headaches Muscle pain
Intergumentary system

A rash Itch (pruritus) and sleep disturbance A growth or lump Discharge, crusting and smell Scales falling from the skin or scalp Disfigurement and psychological distress Inability to work or pursue leisure activities Pallor Alopecia Clubbing Pachyonychia Thick nails

Hepatobiliary Jaundice (icterus) Itch (pruritus)

Nervous system

Yellow discoloration of skin and sclerae Generalized itch

Onycholysis Pterygium

Separation from bed Like extremely dry nails

Endocrine system

Thirst and polyuria Weight loss Weight gain or redistribution Muscle weakness Cold and heat intolerance Increased sweating Tremors Impotence Gynecomastia Amenorrhea Galactorrhoea Excess hair growth Reproductive system Females Menarche Primary amenorrhoea Secondary amenorrhoea Age when periods commence No periods by the age of 16 years No periods for 3 months or more in a woman who previously menstruated regularly Periods occurring at intervals longer than 35 days and/or being particularly light Excessive blood loss Males Postmenopausal bleeding Perimenopause

menstrual period. Only known for certain after no further bleeding for 1 year Time around the menopause when periods become erratic and menopausal symptoms (hot flushes and sweats) occur Spontaneous vaginal bleeding more than 1 year after the final menstrual period

Libido Frequency of intercourse Venereal diseases Discharge from penis Testicular pain Urinary system Kidneys upper urinary tract Pain Usually felt in lumbar regions Swelling Usually of feet/ankles and/or around eyes Macroscopic Blood visible in urine with haematuria naked eye Lower urinary tract Voiding pain Frequency Urgency Nocturia Hesitancy Pain passing urine Passing urine more often than usual An uncontrollable need to pass urine Waking to pass urine during the night Delay in initiating urine flow; seen in bladder outlet obstruction A reduction in the urinary stream Dribbling of urine after

Oligomenorrhoea

Heavy menstrual bleeding (previously called menorrhagia) Flooding Episodes of very heavy menstrual blood loss Painful menstrual Pain prior to or bleeding or during the period dysmenorrhoea Menopause The final spontaneous

Poor flow Post-

micturition dribbling Stress incontinence Urge incontinence General Polyuria Oliguria Anuria Haematuria Pneumaturia Urethral discharge

voiding; usually due to bladder outlet obstruction Involuntary passage of urine related to increased intra-abdominal pressure Involuntary passage of urine related to abnormal detrusor function Passing a larger volume of urine than normal Passing a smaller volume of urine than normal Total absence of urine output Blood in the urine Gas in the urine Purulent material from urethra, suggesting sexually acquired infection

................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. .................

Ear , Nose and Throat Otalgia Pruritus Otorrhoea Pain Itching Discharge

Hearing loss Deafness Tinnitus Noise in the absence of an objective source Vertigo Hallucination of movement Unsteadiness Nystagmus Nose blocked Rhinorrhoea

Discharge ................. ................. ................. ................. .................

Epistaxis Nose bleed Sneezing Coughing Anosmia Absence of smell Hyposmia Reduced smell Cacosmia Unpleasant smell Nasal deformity Pain Septum perforation Summary of the systemic review .................

PHYSICAL EXAMINATION NERVOUS SYSTEM

Coma The Glasgow Coma Scale (GCS) Stupor describes a state where the patient, although inaccessible, shows some response to painful stimuli. It is better to use the GCS score. Torpor is a state of extreme psychiatric disturbance where the patient withdraws mentally from his or her surroundings. Disorientation means that the person is conscious but muddled in time, place and person. Delirium refers to disorientation, or dementia, occurring in the context of drowsiness, or clouding of consciousness, in which the patient is more accessible than in stupor. This functional disorder is better assessed by orientation and by digit span than by GCS score. Dementia consists of impaired cognitive function in the setting of a normal conscious level - the patient is alert and awake, but with a generalized neuropsychiatric deficit. Confusion implies disorientation. An acute confusional state is a state of acute delirium. Dementia causing disorientation without delirium is often described as confusion.

Comprehensive screening neurological examination Conscious level and cognitive function (determined during history taking)

Is the patient's conscious level clouded?

Is the history given accurately, concisely and with insight? Or is the patient concrete, circumlocutory or vague?

Is the patient neatly dressed and well cared for? Is the patient's behaviour normal? Is the patient aphasic or dysarthric?

Vision

Acuity: For each eye, using normal refractive correction, test ability to read small and large print, or use Snellen chart if available. If this fails, test counting of fingers, perception of light. Visual fields: Test all four quadrants for each eye individually. Fundi: Check for papilloedema, optic atrophy, retinopathy. Pupils: Check equality and consensual and direct reactions to light and accommodation. Eye movements

Test both eyes together in 'H' pattern for range of movement and diplopia. Test both eyes together in '+' pattern for smooth pursuit and nystagmus.

Remainder of cranial nerves

Nerve V: Pinprick on left and right in ophthalmic, maxillary and mandibular distributions; clenching of teeth; jaw jerk. Nerve VII: Appearance and symmetry; screwing up eyes against pressure, forcing

lips closed against pressure, blink reflexes. Nerve VIII: Hear whispered numbers in each ear. Nerves IX and X: Ask patient to say 'ah' and observe palate. Nerve XI: Ask patient to shrug shoulders and move head to either side and flex against resistance while you observe sternomastoids. Nerve XII: Inspect tongue. Ask patient to protrude tongue and press against inside of cheek on either side. Limbs and trunk

Inspection for wasting, fasciculation, skin lesions. Posture of outstretched arms with wrists pronated and supinated, looking for drift, tremor, abnormal movements. Tone at wrist, elbows, knees and ankles, ankle clonus. Power of proximal, axial and distal muscles on both sides. Co-ordination: Finger-nose test; rapid alternating movements; heel-shin test. Reflexes: Deep tendon reflexes of biceps, supinator, triceps, fingers, quadriceps, gastrocnemius; plantar responses. Sensation: Test pinprick distally to proximally up arms and legs medially and laterally; and up trunk bilaterally, anteriorly and posteriorly. Vibration sense or joint position sense at little finger, great toe (moving proximally if failed). Gait and stance

Observe walking pattern. Standing still with feet together and eyes closed. Walking heel to toe. Jumping and hopping.

MUSCULOSKELETAL SYSTEM General observations

Gait Posture Mobility Deformity Independence: use of wheelchair or walking aids Muscle wasting Long bones Fractures

Joints Tendons Skin

GALS screen

Ask the patient to undress to their underwear and stand in front of you. Demonstrate actions rather than only telling them what to do.

Gait

Ask the patient to walk ahead in a straight line for several steps, then turn and walk back towards you. Look for smoothness and symmetry of the gait.

Arms

Stand in front of the patient. Gently press the midpoint of each supraspinatus to detect hyperalgesia Ask the patient to put his hands behind the head, with the elbows going back. This tests abduction and external rotation of the glenohumeral joint. Have the patient place the elbows by the side of the body and bend them 90. Turn the palms up and down .This tests pronation and supination at the wrist and elbow. Ask the patient to bend the arms up to touch the shoulders. This tests elbow flexion. Show him how to make a 'prayer sign', bending the wrist back as far as possible. Put the backs of the hands together in a similar fashion. This tests wrist flexion and extension. Have the patient put his arms straight out in front of the body. This tests elbow extension. The patient next clenches the fists, and then opens the hands flat. This tests both wrists and hands. Inspect the dorsum of the hands and check for full finger extension at the metacarpophalangeal (MCP), PIP and DIP joints. Ask him to squeeze your index and middle fingers. This tests the strength of the power grip. Have him touch each finger tip with his thumb. This tests precision grip and problems in co-ordination or concentration. Gently squeeze the patient's metacarpal heads . Tenderness suggests inflammation, e.g. rheumatoid arthritis, involving the MCP and PIP joints.

Legs

Ask the patient to lie supine (face up) on the couch. Carry out Thomas's test for fixed flexion deformity on both hips (if there is no contraindication). Flex each hip and knee with your hand on the patient's knee. Feel for crepitus in patellofemoral joint, knee and hip flexion. Flex the patient's knee and hip to 90, and passively rotate each hip internally and externally, noting pain or limited movement. This tests hip rotation (internal and external). Palpate each knee for warmth and swelling. Check for patellar tap. These detect inflammation and effusions. Look at the feet for any abnormality. Examine the soles looking for calluses and ulcers, indicative of abnormal load bearing. Gently squeeze the metatarsal heads for tenderness

Spine

Stand behind the patient and assess the straightness of the spine, muscle bulk and symmetry in the legs and trunk. Look for any asymmetry at the level of the iliac crests (unilateral leg shortening), and swelling or other abnormality of the gluteal, hamstring, popliteal and calf muscles. Look at the Achilles tendons and hindfoot regions for swelling or deformity. Stand beside the patient and ask him to bend down and try to touch the toes This

highlights any abnormal spinal curvature or limited extension at the hips. Stand behind the patient, hold the pelvis, and ask him to turn from side to side without moving the feet. This tests mainly thoracolumbar rotation. Ask him to slide the hand down the leg towards the knee. This tests lateral lumbar flexion. Stand in front of the patient and ask him to put the ear on the shoulder to test lateral cervical flexion. Ask him to look up at the ceiling and then down at the floor to test cervical flexion and extension. Have the patient let the jaw drop open and move it from side to side. This tests both temporomandibular joints.

RESPIRATORY SYSTEM There is no single perfect way of examining the chest, and most doctors develop their own minor variations of order and procedure. The following is one scheme that combines efficiency with thoroughness:

Observe the patient generally, and the surroundings. Ask the patient's permission for the examination, and ensure they are lying back comfortably at 45. Examine the hands. Check the face for anaemia or cyanosis. Observe the respiratory rate. Inspect the chest movements and the anterior chest wall. Feel the position of the trachea, and check for lymphadenopathy. Feel the position of the apex beat. Check the symmetry of the chest movements by palpation. Percuss the anterior chest and axillae.

Sit the patient forward:

Inspect the posterior chest wall. Percuss the back of the chest. Listen to the breath sounds. Check the vocal resonance. Check the tactile vocal fremitus.

If you are examining a hospital inpatient, always take the opportunity to turn the pillow over before lying the patient back again: a cool, fresh pillow is a great comfort to an ill person.

Listen to the breath sounds on the front of the chest. Check the vocal resonance. Check the tactile vocal fremitus.

Stand back for a moment and reflect upon whether you have omitted anything:

Thank the patient and ensure they are dressed or appropriately covered.

CARDIOVASCULAR SYSTEM

Explain that you wish to examine the chest and ask the patient to remove clothing above the waist. Keep female patients' chest covered with a sheet as far as possible.

Inspect the precordium with the patient sitting at a 45 angle with shoulders horizontal. Look for surgical scars, visible pulsations and chest deformity. Lay your whole hand flat over the precordium to obtain a general impression of the cardiac impulse. Locate the apex beat by laying your fingers on the chest parallel to the rib spaces; if you cannot feel it, ask the patient to roll on to his left side. Assess the character of the apex beat and note its position. Feel for a heave of the right ventricle, using the heel of your hand applied firmly to the left parasternal position. Ask the patient to hold his breath in expiration . Palpate for thrills at the apex and both sides of the sternum using the flat of your fingers. Listen with your stethoscope over the precordium. The earpieces should be angled slightly forward and should fit comfortably. The tubing should be about 25 cm long and thick enough to reduce external sound. Make sure the room is quiet when you are auscultating. Listen at the apex, lower left sternal border, and upper right and left sternal borders with the bell then with the diaphragm. Then listen over the carotid arteries and the left axilla. At each site identify the first and second heart sounds. Assess their character and intensity; note any splitting of the second heart sound. Feel the carotid pulse with your thumb to time any murmur. The first heart sound barely precedes the upstroke of the carotid pulsation, while the second heart sound is clearly out of phase with it. Concentrate in turn on systole (the interval between S1 and S2) and diastole (the interval between S2 and S1). Listen for added sounds and then for murmurs. Soft diastolic murmurs are sometimes described as the 'absence of silence'. Roll the patient on to his left side. Listen at the apex using light pressure with the bell, to detect the mid-diastolic and presystolic murmur of mitral stenosis Ask the patient to sit up and lean forwards, then to breathe out fully and hold his breath .Listen over the right second intercostal space and over the left sternal edge with the diaphragm for the murmur of aortic regurgitation. Note the character and intensity of any murmur heard.

URINARY SYSTEM Inspection

Look for distension (from the enlarged kidneys of polycystic kidney disease, or occasionally in obstructive uropathy). Gross bladder distension causes suprapubic swelling. Look for scars in the loins of renal tract surgery and in the iliac fossae of transplant surgery. A catheter for peritoneal dialysis may be present, or may have left small scars in the midline and hypochondrium. Palpation

Use the fingers of your right hand. Start in the right lower quadrant and palpate each area systematically. A distended bladder is felt as a smooth firm mass arising from the pelvis which disappears after urethral catheterization. Polycystic kidneys have a distinctive nodular surface. Firmly, but gently, push your hands together as the patient breathes out. Ask the patient to breathe in deeply; feel for the lower pole of the kidney moving down between your hands. If this happens, gently push the kidney back and forwards

between your two hands to demonstrate its mobility. This is ballotting, and confirms that this structure is the kidney. If the kidney is palpable, assess its size, surface and consistency. Ask the patient to sit up. Palpate the renal angle firmly but gently. If this does not cause the patient discomfort, firmly (but with moderate force only!) strike the renal angle once with the ulnar aspect of your closed fist after warning the patient what to expect (Fig. 9.11). Percussion

Percussion of the kidneys is unhelpful. Percuss for the bladder over a resonant area in the upper abdomen in the midline and then down towards the symphysis pubis. A change to a dull percussion note indicates the upper border of the bladder. Auscultation

Auscultate to detect bruits arising from the renal arteries. Listen carefully over both loins posteriorly and in the epigastrium, using the stethoscope diaphragm. Renal artery bruits cannot be distinguished from those in adjacent vessels, e.g. the mesenteric arteries, but any abdominal bruits, diminished or absent femoral artery pulses and bruits increase the probability of co-existent atheromatous renal artery disease. Test for ascites which may be found in nephrotic syndrome or in patients having peritoneal dialysis. In men examine the external genitalia and perform a rectal examination and to assess the prostate for benign or malignant change. In female patients, if you suspect malignant disease involving the pelvis, ureters or bladder, perform a vaginal examination.

MALE GENITAL SYSTEM

Explain to the patient what you are going to do and offer a chaperone. Record the chaperone's name; if the offer is refused, record the fact. Allow the patient privacy to undress. Ensure privacy and have a warm, well-lit room with a movable light source. Put on gloves. Ask the patent to stand and expose the area from his lower abdomen to the top of his thighs if you are examining the inguino-scrotal area; ask him to lie on his back to examine the penis or prostate. Look at the whole area for redness, swelling or ulcers. Note the hair distribution: in particular, alopecia or infestation. Shaving the pubic hair may cause dermatitis (inflammation of the dermis) or folliculitis (infection around the base of the hairs, leading to an irritating red rash). Check the groin, perineum and scrotal skin for rashes, intertrigo (infected eczema) in the skin creases, and lymphadenopathy. The penis

Enlarged sebaceous follicles may mimic warts. Numerous uniform pearly penile papules around the corona of the glans are normal. Look at the shaft of the penis and check the position of the urethral opening to exclude a hypospadias (the urethra opening part-way along the shaft of the penis. Retract the prepuce to check for phimosis, adhesions, inflammation, or swellings on the foreskin or glans. Always draw the foreskin forward after examination to avoid a paraphimosis. Examine the glans for red patches or vesicles.

Examine the shaft for sebaceous cysts or hardness (usually on the dorsum) consistent with a plaque of Peyronie's disease. Take a urethral swab if your patient has a discharge or is having sexual health screening. The scrotum

Look at the scrotum for redness, swelling or ulcers; sebaceous cysts are common. Inspect the posterior surface. Note the position of the testes and any paratesticular swelling. Ask the patient whether he is experiencing any genital pain before examining the scrotal contents. If the patient is cold or apprehensive, the dartos muscle will contract and you will not be able to palpate the scrotal contents properly. Palpate the scrotum gently, using both hands. Check that both testes are present in the scrotum; if they are not, examine the inguinal canal and perineum. Place the fingers of both your hands behind the left testis to immobilize it and use your index finger and thumb to palpate the body of the testis methodically. Feel the anterior surface and medial border with your thumb and the lateral border with your index finger. Repeat on both sides. Check the size and consistency of the testis and note any nodules or irregularities. Encourage all younger men to examine their testes regularly and to present any abnormal swellings to their doctor. This helps to detect testicular tumours early. You should barely be able to feel the normal epididymis, except for its head.. Palpate the spermatic cord with your right hand. Gently pull the right testis downward and place your fingers behind the neck of the scrotum. You will be able to feel the spermatic cord and the vas deferens within it, like a thick piece of string. Feeling a 'bag of worms' in the cord suggests a varicocoele. This should disappear when the patient lies down; if it does not, then consider a retroperitoneal mass distending the testicular veins. Decide whether a swelling arises in the scrotum or from the inguinal canal. Use your fingers to see whether you can feel above the swelling; if so, it is a true scrotal swelling. If not, it may be a varicocoele or inguinal hernia, which has descended into the scrotum. If there is a bulky or painful mass in the scrotum and you cannot palpate the testis, request an ultrasound scan to clarify the anatomy of the intrascrotal structure.. The prostate

Carry out a rectal examination. Feel the prostate anteriorly through the rectal wall and assess its size. The normal prostate is a smooth, non-tender structure in the anterior rectal wall. You may feel an indentation or sulcus between the two lateral lobes and sometimes the seminal vesicles above the prostate. Note any tenderness. Assess the consistency. Feel for any nodules. Withdraw your finger. Offer the patient tissues to clean himself up and privacy to get dressed.

FEMALE GENITALIA Vagina

Wash your hands and put on gloves. Look at the vulval area before separating the labia with the forefinger and thumb of your left hand .Inspect the vaginal opening and urethra. Look for discharge, inflammation, atrophy or ulceration. Check for any swelling of the Bartholin's glands: pea-sized mucus glands lying deep to the posterior margins of the labia minora which can become infected or blocked. Ask the patient to cough or strain down, and look for prolapse of the vaginal walls. Note the position and extent of prolapse and any uterine descent. Watch for involuntary leakage of urine (stress incontinence). Speculum examination

Use a vaginal speculum to see the cervix and the vaginal walls, to carry out a cervical smear and to take swabs. Specula are metal or plastic and come in various sizes and lengths. A woman who has been pregnant will need a larger or longer speculum if the cervix is very posterior. Metal specula may be sterilized and re-used. Plastic specula are always disposable. A metal speculum is cold, so warm it under the hot tap. Most women find a speculum examination mildly uncomfortable, so put a small amount of lubricating gel on the tip of each blade, even if you are carrying out a cervical smear. Part the labia with your left hand. Take the speculum in your right hand with the blades closed and the handles positioned towards the woman's left leg. Gently insert the speculum to its full length into the vaginal opening and, as you do so, rotate it through 90, bringing the handles anteriorly. This avoids manipulating around the perianal region, which women may dislike. (If the procedure is being performed under general anaesthetic in theatre, the handles are positioned posteriorly.) If a woman finds the speculum examination difficult, ask her to insert the speculum herself. Gently open the blades of the speculum and identify the cervix. Vaginal squamous epithelium and the endocervical columnar epithelium meet on the cervix. The position of this squamo-columnar junction varies throughout reproductive life and so the cervix can look very different in individual women. Look for any polyps, or a malignancy which would appear vascular and irregular in appearance. If you do not see the cervix immediately, withdraw the speculum slightly, close the blades and press the speculum slightly deeper at a different angle before re-opening the blades. Use pH paper to check the pH of any discharge Take swabs or a cervical smear before performing a bimanual vaginal examination to avoid removing cellular material from the cervix. Remove the speculum and offer tissues and privacy for the woman to tidy herself up. Discuss your findings with her after she is dressed. Bimanual examination of the uterus

Apply lubricating gel to your right index finger, and as you insert it into the vagina, turn your palm upwards. If the woman is tense or experiences discomfort, only use this one finger. Use your index and middle finger in women who are relaxed to enable you to feel more deeply Feel for the cervix in the upper vagina. This points down and feels firm like the tip of the nose. Move the cervix from side to side and note any tenderness (cervical excitation). This can be a sign of infection. With your fingers posterior to the cervix, place your left hand flat on the lower abdomen above the pubic symphysis

Move your vaginal fingers to push the cervix upwards and feel the fundus of the uterus with your left hand. Identify the size, position and surface characteristics of the uterus and any tenderness. If you cannot feel the uterus, it may be retroverted. Put your fingers in the posterior vaginal fornix and try again. Put your fingers in each lateral vaginal fornix in turn, bringing your right hand up towards your left hand on the abdomen, to assess enlargement or tenderness of the ovaries or Fallopian tubes Obstetric examination of the abdomen

Gain an impression of how your patient's pregnancy is proceeding by noting her demeanour from the moment you see her. Is she happy or does she appear exhausted and anxious? Is she pale or breathless? Does she get up with difficulty, and if so, why? Offer her the chance to empty her bladder before you examine her and ask her to collect a specimen of urine for testing. Measure her height and weight. Women <152 cm (5 feet) are more likely to have obstructed labour and small babies. Patients over 100 kg may develop gestational diabetes and have large (macrosomic) babies. Work out the body mass index (BMI) (kg/h2;). Women are at higher risk in pregnancy if the BMI is <20 or >35. Serial weight measurements throughout pregnancy do not reliably predict problems such as pre-eclampsia or intrauterine growth restriction. Measure the patient's blood pressure and check a urine sample using dipstix for glycosuria and proteinuria. Ask her to lie down on a firm but comfortable couch, with her back resting at an angle of 30. Ask her to uncover her abdomen from the lower chest to below her hips and place a sheet over any exposed underwear. Inspection

Look for the abdominal distension caused by the pregnant uterus rising from the pelvis. After 24 weeks you may see fetal movements, which confirm the baby's viability. Increased pigmentation, caused by increased melanocyte activity related to changes in sex hormones, commonly produces a dark line (linea nigra) stretching from the pubic symphysis upwards in the midline, and nipple pigmentation. Striae gravidarum are the red stretch marks of this pregnancy. Striae albicantes are white stretch marks from a previous pregnancy. Note any scars and check the umbilicus, which becomes flattened as pregnancy advances and everted in polyhydramnios (excess amniotic fluid) or multiple pregnancy. Palpation

Use your left hand to feel the uterus abdominally and estimate the height of the uterus above the symphysis pubis. Note any fetal movements. Facing towards the woman's head, use both hands on either side of the fundus to gain an impression of which fetal part is lying there. Use your right hand on the woman's left side. Bring your hands down to palpate the sides of the uterus and identify which side is fuller; fullness suggests that the back is on that side. Now turn to face the patient's feet, so that your left hand is on the woman's left side. Feel the lower part of the uterus to determine the presenting part. Ballot the head by pushing it gently from one side to the other and feel its hardness against your fingers . After 20 weeks measure the fundal height in centimetres. With a tape measure, fix the end at the highest point on the fundus and measure to the symphysis pubis. The highest point is not always in the midline. To avoid bias, do this with the blank side of the tape facing you, so that you only see the measurement on lifting the tape. The

measurement equals the gestation in weeks 3 cm and is an indicator of growth problems in the fetus. In a tall or thin patient, the fundal height may be less than expected; in an obese patient, it may be greater. You may be able to determine the position of the presenting part. When the presentation is cephalic, the vertex or top of the fetal head engages in the occipitolateral position. If the presentation is cephalic, assess how far into the true pelvis the head has descended by estimating how much of the head you can feel above the pelvic brim. The head is divided into fifths. The head is said to be fixed when it is three-fifths palpable and engaged when it is two-fifths or one-fifth palpable. Percussion

Percussion is unhelpful unless you suspect polyhydramnios. Confirm this by eliciting a fluid thrill but no shifting dullness.

SUMMARY OF PHYSICAL EXAM General ... Gastrointestinal ... Respiratory ... Cardiovascular ...

Genital system ...

Urinary system ... Nervous system ... Locomotor system ...