From the Guidelines
A comprehensive OBGYN history and physical should prioritize questions and findings related to obstetric history, including previous pregnancy complications, to identify women at increased risk of future cardiovascular disease. When evaluating a patient's obstetric history, it is essential to ask about previous pregnancy complications, such as hypertensive disorders of pregnancy, gestational diabetes mellitus, preterm birth, placental abruption, and stillbirth, as these conditions are associated with an increased risk of future cardiovascular disease 1. Key components of an OBGYN history and physical include:
- Documenting gravidity, parity, number of term/preterm births, abortions, and living children (GTPAL)
- Recording last menstrual period, estimated gestational age, and pregnancy symptoms
- Asking about previous pregnancy complications, mode of delivery, birth weights, and any congenital anomalies
- Recording age at menarche, menstrual pattern, sexual history, contraceptive use, sexually transmitted infection history, and previous gynecologic procedures or surgeries
- Including medical, surgical, family, and social histories with particular attention to conditions affecting reproductive health
- Documenting current medications, allergies, and substance use The physical examination should include:
- Vital signs
- General appearance
- Abdominal examination
- Pelvic examination with speculum and bimanual components
- Breast examination when indicated
- Measuring fundal height, assessing fetal heart tones, and documenting fetal movement after viability for pregnant patients These elements provide crucial information for diagnosis, risk assessment, and development of appropriate management plans, including postpartum cardiovascular risk screening and management to reduce the risk of future cardiovascular disease 1.
From the Research
History and Physical Examination in OBGYN
The history and physical examination are essential components of an OBGYN (Obstetrics and Gynecology) visit. The following are some of the most pertinent questions and findings to include in an OBGYN history and physical:
- Medical history: including current and past medical conditions, surgeries, and allergies 2
- Gynecologic history: including menstrual history, pregnancy history, and history of gynecologic conditions such as cervical dysplasia or gynecologic malignancy 3
- Sexual history: including history of sexually transmitted infections and current sexual activity 3, 4
- Family history: including history of gynecologic conditions or other relevant medical conditions in family members 2
Physical Examination
The physical examination should include:
- Pelvic examination: which may be performed based on medical history or symptoms, rather than as a routine screening tool for asymptomatic women 3, 5
- Breast examination: which is not necessary prior to provision of hormonal contraception, but may be performed as part of a routine health examination 4
- Other relevant examinations: such as abdominal or neurological examinations, based on the patient's medical history and symptoms 2
Communication and Shared Decision-Making
Effective communication and shared decision-making are essential components of an OBGYN visit. This includes:
- Active listening and empathetic communication: to gather relevant information and establish a therapeutic relationship with the patient 2, 6
- Cultural sensitivity: to provide care that is sensitive to the patient's cultural and individual needs 2
- Shared decision-making: to involve the patient in decisions about their care, including the decision to perform a pelvic examination 3