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Gynecology & Obstetrics History Taking (MBBS Ward Guide)

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1. Patient Identification (Biodata)

• Name, Age, Address
• Marital status, Duration of marriage
• Occupation (patient and husband)
• Religion (relevant for certain practices)
• Date of admission

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2. Chief Complaint (CC)

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3. History of Present Illness (HPI)

• Onset - When did it begin? Sudden or gradual?
• Character - Nature of complaint (e.g., colicky, dull, burning)
• Duration - How long has it been present?
• Severity - Mild, moderate, severe? Effect on daily activities?
• Radiation - Does pain go anywhere?
• Associated symptoms - Any related complaints?
• Aggravating/Relieving factors
• Timing - Constant or intermittent? Related to menstrual cycle?

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4. Menstrual History (MH) - The Most Important Part of Gynec History

• Menorrhagia: heavy regular periods
• Metrorrhagia: irregular bleeding between periods
• Menometrorrhagia: heavy and irregular
• Oligomenorrhea: periods >35 days apart
• Amenorrhea: no periods for >3 months (secondary) or never started (primary)
• Dysmenorrhea: painful periods

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5. Obstetric History (OH)

• Year of delivery
• Place of delivery (home/hospital)
• Duration of pregnancy (term/preterm/post-term)
• Mode of delivery (normal vaginal / LSCS / forceps / vacuum) - if LSCS, reason?
• Birth weight and sex of baby
• Any complications during pregnancy (hypertension, diabetes, antepartum hemorrhage)
• Any complications during/after delivery (PPH, retained placenta, eclampsia)
• Puerperium - any fever, breast problems, wound issues?
• Outcome of baby - alive and well, neonatal death, congenital anomaly?

• Date of LMP
• Expected Date of Delivery (EDD) - LMP + 9 months + 7 days (Naegele's rule)
• Gestational age in weeks
• Fetal movements - when first felt (quickening)? Frequency now?
• Antenatal visits done? Investigations done (blood group, Hb, ultrasound)?
• Any complications in this pregnancy?

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6. Contraceptive History

• Type of contraceptive used (OCP, IUCD, condoms, sterilization, injectable)
• Duration of use
• Compliance and side effects
• Reason for stopping

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7. Sexual History

• Age at first intercourse (coitarche)
• Number of partners
• Dyspareunia (pain during intercourse - superficial or deep?)
• Any history of STIs

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8. Past Medical History (PMH)

• Any previous medical illnesses: hypertension, diabetes, thyroid disorder, epilepsy, TB, cardiac disease
• Previous surgeries (especially abdominal/pelvic): cesarean section, myomectomy, appendicectomy, D&C
• Previous hospitalizations
• Blood transfusions

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9. Family History (FH)

• Hypertension, diabetes (especially relevant in obstetrics)
• Twins (familial tendency)
• Breast cancer, ovarian cancer, cervical cancer, colorectal cancer
• Congenital anomalies or genetic diseases
• BRCA1/BRCA2 mutations (if relevant)
• Bleeding disorders

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10. Personal and Social History

• Marital status and duration of marriage
• Consanguinity (cousin marriage - important for genetic conditions)
• Socioeconomic status
• Diet and nutrition (especially in pregnancy - iron, folic acid)
• Smoking, alcohol, substance use
• Occupation - exposure to toxins, radiation, stress
• Domestic violence screening (sensitively)
• Level of education

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11. Drug and Allergy History

• Current medications including oral contraceptive pills, hormone therapy
• Over-the-counter and herbal medications
• Known drug allergies - drug name and type of reaction

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12. Review of Systems (ROS)

• Urinary symptoms: frequency, urgency, incontinence, dysuria (urogynecology)
• Bowel symptoms: constipation, dyschezia (pain on defecation - endometriosis)
• Respiratory/cardiovascular: relevant in obstetric patients with comorbidities
• Weight changes, fatigue, heat/cold intolerance (thyroid)

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Quick Memory Aid for Gynaec History

• Biodata
• Chief Complaint
• Menstrual History
• Obstetric History
• Past medical/surgical history
• Sexual and Contraceptive History
• Family History
• Personal/Social History
• Allergy and Drug History
• Drug Review of Systems

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Special Notes for Ward Bedside Clerking

1. Always begin by introducing yourself and ensuring privacy.
2. The LMP is the single most important date in both gynec and obstetric history.
3. In obstetrics, always confirm fetal movements and calculate gestational age yourself.
4. Menstrual history must precede the physical exam - it guides what you look for.
5. Record the obstetric history as G_P_A_L_ notation at the top of your write-up.
6. Ask about domestic violence and sexual history privately, without the husband or family present.
7. For a gynec patient, also ask about last Pap smear and any prior abnormal cervical results.

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Gynecology & Obstetrics: Complete History + Examination in Chronological Order

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PART A: HISTORY TAKING (Chronological Order)

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Step 1 - Patient Introduction & Setting

• Introduce yourself by name and role
• Ensure privacy (close curtains, ask relatives to step out - especially for sexual/social history)
• Obtain verbal consent for history and examination
• Note: husband/partner should NOT be present for sensitive parts

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Step 2 - Biodata

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Step 3 - Chief Complaint (CC)

• "Bleeding per vaginum since 3 months"
• "No period since 4 months with nausea"
• "Lower abdominal pain for 2 weeks"

Textbook tip: "Allow the patient to talk about her chief symptom. Do not interrupt the patient's account, except for minor promptings such as 'When did it begin?' and 'How did it begin?'" - Berek & Novak's Gynecology

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Step 4 - History of Present Illness (HPI)

1. Onset - Sudden or gradual? Date of first appearance?
2. Duration - How long has it been going on?
3. Character - Nature of the symptom
4. Severity - Mild/moderate/severe? Effect on daily life?
5. Aggravating and relieving factors
6. Associated symptoms - Ask related complaints
7. Temporal relationship - Is it related to menstrual cycle / pregnancy?
8. Previous similar episodes
9. Treatment taken so far - What was given? Did it help?

• Systemic symptoms: fever, weight loss, fatigue, anorexia (suggest malignancy or systemic illness)
• Psychological reaction: anxiety, depression, fear

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Step 5 - MENSTRUAL HISTORY (MH) - Unique to Gynecology

• Menorrhagia: Heavy regular periods (>80 mL or >7 days)
• Metrorrhagia: Irregular/intermenstrual bleeding
• Menometrorrhagia: Heavy AND irregular
• Oligomenorrhea: Cycles >35 days apart
• Amenorrhea: Primary (never menstruated by 16) / Secondary (absent >3 months)
• Dysmenorrhea: Painful periods - Primary (no pathology) / Secondary (endometriosis, fibroids)
• Polymenorrhea: Cycles <21 days

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Step 6 - OBSTETRIC HISTORY (OH)

1. Year of delivery
2. Where delivered (home/hospital)
3. Gestational age (term / preterm / post-term)
4. Mode of delivery: Normal vaginal / LSCS (if LSCS - what was the indication?) / Forceps / Vacuum
5. Baby sex and birth weight
6. Complications in pregnancy (APH, PIH, GDM)
7. Complications in labor/delivery (prolonged labor, PPH, perineal tear)
8. Puerperium (fever, wound infection, breast problems)
9. Outcome of baby (healthy / stillbirth / neonatal death / congenital anomaly)

• LMP and EDD (Naegele's rule: LMP + 9 months + 7 days)
• Gestational age in completed weeks
• Quickening (first fetal movements felt) - multigravida ~18 weeks, primigravida ~20 weeks
• Current fetal movements - frequency, any reduction?
• Antenatal visits attended (ANC)
• Investigations done (Hb, blood group, VDRL, HIV, obstetric ultrasound)
• Any complications in this pregnancy

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Step 7 - Contraceptive History

• Type used: OCP / IUCD / condom / injectable / sterilization / barrier
• Duration of use
• Compliance and side effects
• Reason for stopping

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Step 8 - Sexual History

• Sexually active? Age at first intercourse?
• Number of partners
• Dyspareunia - pain during intercourse? Superficial (introital) or deep (pelvic)?
• Any history of STI (gonorrhea, chlamydia, herpes, HPV)
• Last Pap smear and result

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Step 9 - Past Medical and Surgical History

• Hypertension, diabetes, thyroid disease, epilepsy, TB, cardiac disease, asthma
• Previous surgeries: cesarean section, myomectomy, appendicectomy, D&C, tubal ligation
• Previous hospitalizations
• Blood transfusions

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Step 10 - Family History

• Hypertension, diabetes (especially important in obstetric patients)
• Multiple pregnancies (twins)
• Breast, ovarian, cervical, colorectal cancer
• BRCA1/BRCA2 carriers
• Congenital anomalies or genetic diseases
• Bleeding disorders

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Step 11 - Personal and Social History

• Marital status and duration
• Consanguinity (cousin marriage - important for genetic disorders)
• Socioeconomic status
• Diet and nutrition (iron, folic acid in pregnancy)
• Smoking (pack-years), alcohol, recreational drugs
• Occupation - occupational hazards, radiation exposure
• Domestic violence (ask sensitively, alone)

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Step 12 - Drug and Allergy History

• Current medications (OCP, HRT, iron, folic acid, antihypertensives)
• Herbal and over-the-counter medications
• Known drug allergies (drug name + reaction type)

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Step 13 - Review of Systems (ROS)

• Urinary: frequency, urgency, leakage (urogynecology)
• Bowel: constipation, dyschezia (pain on defecation - endometriosis)
• General: weight loss, fatigue, heat/cold intolerance (thyroid)
• Breast: discharge, lump, pain

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PART B: PHYSICAL EXAMINATION (Chronological Order)

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Step 1 - General Physical Examination (GPE)

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Step 2 - Breast Examination

• Size and symmetry
• Skin changes: peau d'orange, erythema, dimpling, retraction
• Nipple changes: inversion, discharge, ulceration

• All four quadrants + axillary tail + nipple-areola complex
• Any mass: site, size, shape, surface, consistency, tenderness, mobility, margin, skin fixity
• Axillary lymph nodes (anterior, posterior, central, apical groups)
• Supraclavicular nodes

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Step 3 - Abdominal Examination

Inspection

• Shape: flat, scaphoid, distended
• Symmetry
• Any visible mass or distention (gravid uterus? Ovarian cyst?)
• Umbilicus: central/displaced, inverted/everted
• Skin: linea nigra, striae gravidarum (pregnancy), striae albicans (old), surgical scars
• Movements: with respiration

Palpation

• Check for tenderness first (ask patient to point to painful area - examine that area last)
• All four quadrants systematically (clockwise from right upper quadrant)
• Liver edge (ask to breathe in/out)
• Spleen
• Uterus/pelvic mass: size (in weeks of gestation from pubic symphysis), surface, consistency, tenderness, mobility
• Rebound tenderness (peritoneal irritation)
• Free fluid/ascites: shifting dullness, fluid thrill

For Obstetric Patients - Uterine Size

For Obstetric Patients - Leopold's Maneuvers (from 30 weeks)

Percussion

• Shifting dullness for ascites (ovarian cancer)
• Percuss uterine mass if gynec case

Auscultation

• Bowel sounds
• Fetal heart tones (obstetric)

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Step 4 - Pelvic Examination

• Patient empties bladder
• Chaperone present (mandatory)
• Patient's consent obtained
• Good lighting
• Patient in dorsal lithotomy position

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A. Inspection of External Genitalia

1. Mons pubis, labia majora, labia minora, perineal body, anal region
2. With labia separated:
   • Labia minora
   • Clitoris (size, any abnormality)
   • Urethral orifice (any caruncle, discharge)
   • Vaginal introitus/hymen
   • Perineal body
   • Anus
3. Note: skin quality, pigmentation, erythema, lesions, excoriations, ecchymosis, swelling
4. Ask patient to bear down: observe for cystocele (anterior bulge), rectocele (posterior bulge), uterine prolapse
5. Check Bartholin's glands (posterior labia majora) - swelling, tenderness, cyst/abscess
6. Check Skene's glands (paraurethral) - milk undersurface of urethra for discharge if indicated

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B. Speculum Examination

1. Warm the speculum
2. Insert obliquely with downward pressure (not into urethra)
3. Rotate and open blades under vision

• Vaginal walls: color, rugosity, discharge (amount, color, odor, consistency), lesions
• Cervix: size, shape (multiparous - transverse os; nulliparous - pinpoint), color, ectopy/erosion, polyps, ulcers, bleeding, abnormal discharge from os
• Collect Pap smear / HVS / endocervical swab if indicated

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C. Bimanual Palpation

1. Vagina: Note tenderness, masses, structural abnormality
2. Cervix:
   • Position (anterior/posterior)
   • Consistency (firm/soft - Hegar's sign in pregnancy = soft isthmus)
   • Surface irregularity
   • Cervical motion tenderness (CMT): gentle movement of cervix - pain indicates pelvic inflammatory disease
3. Uterus (coordinate both hands):
   • Position: anteflexed / retroflexed / anteverted / retroverted
   • Size: normal (pear-sized, 7-8 cm) or enlarged (in weeks)
   • Shape: regular or irregular (fibroids)
   • Consistency: firm/soft
   • Tenderness
   • Mobility
4. Right adnexa (right lateral fornix + right iliac fossa):
   • Normal tube is not palpable
   • Normal ovary: ~4×2×3 cm, slightly tender, mobile
   • Mass: size, consistency, tenderness, mobility, relationship to uterus
5. Left adnexa: same technique on left side
6. Posterior fornix / Pouch of Douglas (POD): any fullness, tenderness, nodularity (endometriosis)

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D. Recto-vaginal Examination

• Index finger in vagina, middle finger in rectum
• Allows palpation higher in the pelvis beyond the POD
• Checks uterosacral ligaments (nodularity = endometriosis)
• Checks rectal mucosa
• Essential if retroversion of uterus is suspected
• In women with intact hymen: rectal-abdominal examination only

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E. Rectal Examination

1. Inspect perianal area: skin tags, fissures, fistula, hemorrhoids, pilonidal sinus
2. Insert lubricated gloved finger
3. Note anal sphincter tone
4. Palpate rectal wall circumferentially
5. In gynec: feel for cervix, posterior uterine wall, uterosacral ligaments

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Step 5 - Vaginal (Per Vaginum) Examination in Labor (Obstetric)

• Dilatation + Effacement + Station + Consistency + Position
• Score ≥8 = favorable cervix

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SUMMARY: Full Chronological Sequence for Ward

HISTORY
1. Biodata
2. Chief Complaint + Duration
3. History of Present Illness
4. Menstrual History (LMP, cycle, duration, flow, dysmenorrhea)
5. Obstetric History (G_P_A_L_ + each pregnancy details)
6. Contraceptive History
7. Sexual History
8. Past Medical + Surgical History
9. Family History
10. Personal + Social History
11. Drug + Allergy History
12. Review of Systems

EXAMINATION
1. General Physical Examination (GPE) + Vitals
2. Breast Examination
3. Abdominal Examination
   - Inspection
   - Palpation (± Leopold's maneuvers in obstetric cases)
   - Fundal height measurement
   - Fetal heart auscultation (obstetric)
   - Percussion
   - Auscultation
4. Pelvic Examination (lithotomy position)
   A. External genitalia inspection
   B. Speculum examination (vagina + cervix)
   C. Bimanual palpation (vagina, cervix, uterus, adnexa)
   D. Recto-vaginal examination
   E. Rectal examination
5. Per Vaginum (PV) examination (if in labor - obstetric)

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Do CNS and Other Systemic Examinations Apply in Gynecology/Obstetrics?

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The Golden Rule for MBBS Students

In Gynecology/Obstetrics, the examination is problem-directed. The systems you examine depend on the diagnosis you are suspecting.

1. Routine for every patient - GPE + breast + abdomen + pelvis (as covered before)
2. Condition-specific - added systems based on the clinical situation

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System-by-System Breakdown

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1. CNS (Neurological) Examination

• Patellar reflex (knee jerk) - checked before EVERY dose of MgSO4 in eclampsia management
• Ankle clonus (>3 beats = pathological) - sign of CNS irritability in preeclampsia
• Papilledema on fundoscopy - raised ICP in severe preeclampsia

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2. Cardiovascular System (CVS) Examination

• Pulse - rate, rhythm, volume, character
• Blood pressure - both arms if needed
• JVP
• Precordium - inspection, palpation (apex beat), percussion, auscultation (heart sounds, murmurs)
• Peripheral pulses

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3. Respiratory System (RS) Examination

• Respiratory rate
• Chest expansion
• Tactile vocal fremitus
• Percussion note
• Auscultation - air entry, added sounds (crepitations, wheezes, pleural rub)

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4. Thyroid Examination

• Inspection of neck (visible goiter?)
• Palpation - size, surface, consistency, bruit, mobility on swallowing
• Auscultation - thyroid bruit (hyperthyroidism)
• Signs of hypothyroidism: dry skin, hair loss, bradycardia, delayed ankle reflex, periorbital puffiness
• Signs of hyperthyroidism: tremor, warm moist skin, tachycardia, exophthalmos, lid lag

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5. Musculoskeletal / Spine Examination

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6. Eyes (Ophthalmic) Examination

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7. Skin and Mucous Membranes

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8. Lymph Nodes

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Practical Summary Table

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How to Write It in Your Case Sheet

SYSTEMIC EXAMINATION

Cardiovascular System:
- Heart rate: 82/min, regular
- BP: 130/90 mmHg
- S1 S2 heard, no murmurs

Respiratory System:
- Respiratory rate: 18/min
- Air entry equal bilaterally, no added sounds

Per Abdomen: (detailed - as discussed)

Per Speculum / Per Vaginum: (detailed)

CNS: Conscious, oriented. No focal neurological deficit.
Deep tendon reflexes - normal bilaterally.
[Add: Patellar reflex present (if on MgSO4 - state this explicitly)]

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Bottom Line

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Complete Physical Examination - Gynecology & Obstetrics

Full Chronological Order with Understanding

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The Universal Order: GPE → Hands → Pulse → BP → JVP → Eyes/Face → Neck → Breast → CVS → RS → Abdomen → CNS (when indicated) → Pelvic Examination

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STEP 1 - PREPARATION (Before You Touch the Patient)

1. Wash hands / use sanitizer in front of the patient
2. Introduce yourself - "I am [name], a medical student/intern"
3. Take consent - "May I examine you?"
4. Ensure privacy - close curtains/door
5. Chaperone - always present for pelvic exam; ideally a female nurse
6. Position the patient - supine initially, pillow under head, arms relaxed by side
7. Adequate lighting - essential
8. Ask patient to empty bladder before abdominal and pelvic exam

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STEP 2 - GENERAL PHYSICAL EXAMINATION (GPE)

A. General Appearance - Observe First

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B. Anthropometry

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C. Vital Signs

1. Pulse

In obstetrics: Pulse >100 in a laboring patient should alert you to hemorrhage, sepsis, or severe anemia.

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2. Blood Pressure

1. Palpate brachial artery (antecubital fossa, medial side)
2. Apply cuff 2-3 cm above antecubital fossa - snugly
3. Palpate radial pulse, inflate cuff until pulse disappears, then +30 mmHg
4. Deflate slowly at 2 mmHg/second
5. Korotkoff sounds: Phase I (first sound) = Systolic; Phase V (disappearance) = Diastolic

Always take BP in both arms if you suspect aortic coarctation or if BP is high. Take it in the left lateral decubitus position in late pregnancy to avoid aortocaval compression.

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3. Temperature

• Use digital thermometer (axillary or oral)
• Normal: 36.5°C - 37.5°C
• Fever: >38°C - think PID, chorioamnionitis, postpartum sepsis, UTI
• Record as: "Afebrile" or "Febrile (38.4°C)"

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4. Respiratory Rate

• Count chest wall movements for a full minute (or 30 sec × 2) without telling the patient
• Normal: 12-20 breaths/min
• Tachypnea: >20 - pulmonary edema, sepsis, pulmonary embolism, anemia
• Record with the pulse (don't do it separately or patient will breathe abnormally)

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D. Peripheral Signs (Hands to Head)

HANDS

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EYES - LOOK AT THESE CAREFULLY

How to grade pallor: Pull down lower eyelid gently. Pale pink/white conjunctiva = pallor. Grade: Mild = pale but some color. Moderate = distinctly pale. Severe = white/almost no color.

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FACE

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TONGUE AND MOUTH

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NECK - THYROID

• Size: which lobe enlarged?
• Surface: smooth (diffuse) or nodular?
• Consistency: soft / firm / hard
• Tenderness: thyroiditis
• Moves on swallowing? Tethering?
• Tracheal deviation?
• Cervical lymph nodes: pre/post-auricular, submandibular, anterior/posterior cervical chains, supraclavicular

Why thyroid matters in gynec/obs: Hypothyroidism causes menstrual irregularity, infertility, galactorrhea. Hyperthyroidism causes tachycardia, irregular cycles. Both must be excluded in infertility and AUB workup.

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LYMPH NODES (General)

1. Submandibular (under chin)
2. Cervical - anterior and posterior chain
3. Supraclavicular - Virchow's node (left side) = ovarian/cervical cancer metastasis
4. Axillary - breast cancer
5. Inguinal - vulvar cancer, STIs, lower limb infections

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EDEMA

In obstetrics: Grade 1+ pedal edema is physiological in pregnancy (from 30 weeks). Facial edema + rapid weight gain + HTN = preeclampsia until proven otherwise.

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STEP 3 - BREAST EXAMINATION

Inspection (Patient Sitting, Good Lighting)

1. Arms by sides - baseline
2. Arms raised above head - reveals skin dimpling, tethering
3. Hands pressed on hips (pectoral contraction) - reveals subtle tethering
4. Leaning forward - pendulous breasts: asymmetry, nipple position

Palpation (Patient Supine, Arm Behind Head)

• Divide into 4 quadrants + axillary tail (Tail of Spence)
• Or use clockwise concentric circles from nipple outward
• Include the nipple-areola complex last (gentle squeeze for discharge)

1. Site (which quadrant, distance from nipple)
2. Size (in cm)
3. Shape (spherical / irregular)
4. Surface (smooth / nodular)
5. Consistency (soft / firm / hard / fluctuant)
6. Tenderness
7. Mobility (freely mobile / attached to skin / attached to muscle)
8. Skin over it (normal / peau d'orange / dimpled)
9. Margin (well-defined / ill-defined)

Axillary Lymph Node Examination

1. Anterior group (pectoral nodes) - under pectoralis major
2. Posterior group (subscapular) - along posterior axillary fold
3. Central group - central axilla
4. Lateral group - medial to humerus
5. Apical group - apex of axilla (feel with fingers pointing upward)
6. Supraclavicular nodes - above clavicle, medial to sternocleidomastoid

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STEP 4 - CARDIOVASCULAR SYSTEM (CVS) EXAMINATION

A. Inspection of the Precordium and Neck

• Patient at 45° angle, head slightly turned left
• Look for internal jugular vein pulsation in the right side of neck (between the two heads of sternocleidomastoid)
• Measure height of venous column above the sternal angle in cm, then add 5 cm (sternal angle is 5 cm above right atrium)
• Normal JVP: ≤3 cm above sternal angle (i.e., ≤8 cm H₂O total)
• Raised JVP: cardiac failure, fluid overload, cardiac tamponade
• JVP vs carotid pulse: JVP is non-palpable, has 2 waves per beat, falls on inspiration, disappears with pressure on the root of the neck

B. Palpation of Precordium

C. Percussion of the Heart

• Left cardiac border: percuss from axilla medially along each ICS (3rd, 4th, 5th) until dull
• Less commonly done; echocardiography has largely replaced this
• Still useful for bedside assessment of cardiomegaly

D. Auscultation - The Most Important Part

1. Use diaphragm first (high-pitched sounds: S1, S2, systolic murmurs)
2. Then bell (low-pitched sounds: S3, S4, mitral stenosis rumble)
3. Auscultate each area: listen for S1, S2, added sounds, murmurs

• Timing: systolic / diastolic / continuous
• Grade: I-VI (I = barely heard, VI = heard without stethoscope)
• Location: where loudest?
• Radiation: to axilla (MR), to carotids (AS), to back (PS)
• Character: harsh, blowing, rumbling

In Obstetrics: Pregnancy produces a physiological ejection systolic murmur (grade 1-2/6) due to increased cardiac output - this is normal. A diastolic murmur is always pathological. Any diastolic murmur in a pregnant woman = echocardiogram urgently.

E. Peripheral Vascular Examination

• All peripheral pulses: radial, brachial, femoral, popliteal, dorsalis pedis, posterior tibial
• Capillary refill time: Press nail bed for 5 seconds, release. Normal refill <2 seconds. >2 seconds = poor perfusion
• Ankle edema: already described above

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STEP 5 - RESPIRATORY SYSTEM (RS) EXAMINATION

A. Inspection

• Spine: kyphosis, scoliosis (affects lung function + anesthesia planning)
• Cyanosis: peripheral (blue fingers) vs central (blue tongue)

B. Palpation

• Stand in front of patient
• Place index finger in suprasternal notch - feel which side the trachea is on
• Normal = central
• Deviated TOWARD lesion = lung collapse, fibrosis
• Deviated AWAY from lesion = massive pleural effusion, tension pneumothorax

• Place both hands symmetrically on the BACK of the chest (lower zones), thumbs meeting in the midline, fingers spread laterally
• Ask the patient to take a deep breath
• Watch your thumbs: they should move apart equally
• Normal: 5-7 cm expansion
• Reduced on one side: problem on that side
• Reduced bilaterally: COPD, fibrosis, pregnancy

• Place ulnar edge of hand (or palm) on chest wall
• Ask patient to say "99" or "one-two-three"
• Move hand systematically comparing sides
• Normal: moderate vibration felt symmetrically
• Increased TVF: consolidation (sound transmits better through solid lung)
• Decreased TVF: pleural effusion (fluid blocks transmission), pneumothorax, collapse

C. Percussion

• Place middle finger of left hand flat on chest wall (pleximeter) parallel to ribs
• Strike the middle phalanx of that finger with the tip of middle finger of right hand (plexor) in a quick wrist-flick motion
• Strike twice and listen carefully
• Move systematically: top to bottom, comparing left and right sides

• Front: 3 areas each side (clavicle, 2nd ICS, 4th ICS)
• Back: 5 areas each side (above spine of scapula, interscapular ×2, below scapular ×2)
• Axilla: compare both sides

• Liver dullness: Percuss down from right side anteriorly - dullness starts at 5th ICS (liver upper border)
• Cardiac dullness: Left side anteriorly
• Stony dullness at base + absent TVF = pleural effusion (very important in preeclampsia and cardiac disease in pregnancy)

D. Auscultation

What to specifically look for in gynaec/obs:

• Basal crepitations = pulmonary edema in preeclampsia or cardiac failure
• Absent breath sounds + stony dullness at base = pleural effusion
• Wheeze = asthma (common comorbidity) or cardiac asthma

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STEP 6 - ABDOMINAL EXAMINATION

A. Inspection

B. Palpation

Superficial Palpation

• All 9 regions systematically (or 4 quadrants)
• Light touch - feel for guarding, rigidity, superficial tenderness
• Watch the patient's face while palpating (they will wince if it hurts)
• Guarding = voluntary muscle contraction when you touch (patient knows it will hurt)
• Rigidity = involuntary board-like hardness (peritonism)

Deep Palpation

• Same 9 regions with deeper pressure
• Feel for organs and masses

• Start in the RIGHT ILIAC FOSSA, move upward toward the right subcostal margin
• Ask patient to breathe in and out - feel the liver edge come down on inspiration
• Normal liver: not palpable below the costal margin, or barely palpable
• If enlarged: describe in finger-breadths below costal margin, surface, consistency, tenderness

• Start in the RIGHT ILIAC FOSSA, move diagonally toward LEFT hypochondrium
• Ask to breathe in - feel the splenic notch
• Cannot get above the spleen (vs kidney)
• Ballottement test for floating kidney

• Start from the umbilicus and move toward the pubis
• Identify the upper border of the mass
• Measure in cm from pubic symphysis OR describe in relation to umbilicus
• Uterus 12 weeks = pubic symphysis level; 20 weeks = umbilicus; 36-40 weeks = xiphisternum

C. Percussion

• All 9 regions to map any dullness
• Shifting dullness for ascites: percuss from umbilicus laterally until dull. Keep finger there, ask patient to roll toward you. Dullness shifts to resonant = fluid has moved (positive shifting dullness = ascites)
• Fluid thrill: Place patient's or assistant's hand on midline. Flick one flank - feel thrill on other flank (large amounts of ascites)
• Percuss the uterine mass: dull

D. Auscultation (Before Deep Palpation Technically - Do It After Inspection in Practice)

• Listen for bowel sounds for at least 30 seconds
• Normal: gurgling sounds every 5-15 seconds
• Increased/tinkling = intestinal obstruction (early)
• Absent = paralytic ileus, peritonitis, post-operative

For Obstetric Patients - Fundal Height

• Larger than dates: Multiple pregnancy, polyhydramnios, LGA baby, fibroids, wrong dates
• Smaller than dates: FGR, oligohydramnios, wrong dates, fetal demise

For Obstetric Patients - Leopold's Maneuvers (from 28-30 weeks)

• Use Pinard's stethoscope (place directly on abdomen, your ear against it) or Doppler probe
• FHR is best heard through the fetal back
• In LOA (left occiput anterior) = listen in the left lower quadrant
• In ROA = right lower quadrant
• Normal FHR: 110-160 beats/min
• Count for 1 full minute
• Bradycardia (<110) = fetal distress, cord compression
• Tachycardia (>160) = maternal fever, fetal anemia, early hypoxia

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STEP 7 - CNS (NEUROLOGICAL) EXAMINATION

• Preeclampsia/Eclampsia
• On MgSO4 therapy (before every dose)
• Postpartum headache (rule out CVST)
• Prolactinoma/pituitary tumor (infertility workup)
• Any altered consciousness

A. Mental Status

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B. Cranial Nerve Screening (Relevant in Gynec/Obs)

• Sit directly facing the patient at arm's length
• Both cover one eye each (you cover your opposite eye)
• Bring a finger in from the periphery in all quadrants
• Pituitary tumor pressing on optic chiasm → Bitemporal hemianopia = loss of peripheral (temporal) vision in both eyes

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C. Motor System

• 5 = Normal power
• 4 = Movement against gravity + some resistance
• 3 = Movement against gravity only
• 2 = Movement with gravity eliminated
• 1 = Flicker of movement
• 0 = No movement

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D. Sensory System (Brief Screen)

• Light touch: cotton wool on both sides simultaneously (compare)
• Pain: pin-prick (compare both sides)
• If asymmetry is found, map the level

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E. Deep Tendon Reflexes - THE MOST IMPORTANT IN OBSTETRICS

• Hold the patient's foot
• Sharply and firmly dorsiflex the foot (push toes upward)
• Maintain the dorsiflexion
• Feel for rhythmic beats of the ankle
• Normal: 0-2 beats
• Pathological: 3 or more sustained beats = clonus = upper motor neuron lesion / CNS irritability
• In preeclampsia/eclampsia: clonus indicates severe CNS irritability, imminent seizure risk

THE RULE: Before every dose of MgSO4:

• Patellar reflex must be PRESENT (absence = MgSO4 toxicity → stop the infusion)
• Respiratory rate must be >16/min
• Urine output must be >25 mL/hour

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F. Plantar Reflex (Babinski's Sign)

• Run a blunt key or orange stick along the outer border of the sole, from heel to little toe, then curving medially
• Normal (flexor): toes flex downward
• Abnormal (extensor/Babinski positive): big toe extends upward + other toes fan out
• Babinski positive = upper motor neuron lesion (stroke, severe metabolic encephalopathy, post-ictal state after eclampsia)

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STEP 8 - PELVIC EXAMINATION

Position

• Lying on back
• Buttocks at the edge of the examination table
• Feet in stirrups, hips and knees flexed
• Good lighting directed at perineum

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A. External Genitalia - Inspection

1. Mons pubis - distribution of pubic hair (sparse = hormonal; escutcheon pattern)
2. Labia majora - swelling, ulcers, discoloration, varicosities (common in pregnancy)
3. Labia minora - color, lesions, hypertrophy
4. Clitoris - size (enlargement = virilization, androgen excess)
5. Urethral orifice - urethral caruncle, discharge, prolapse
6. Vaginal introitus - patency, hymen remnants, discharge
7. Perineal body - scars (old tear / episiotomy), fistula
8. Anus - hemorrhoids, fissure, skin tags, fistula, warts

• Anterior vaginal wall bulge = Cystocele (bladder prolapse)
• Posterior wall bulge = Rectocele (rectum prolapse)
• Cervix/uterus descending = Uterine prolapse

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B. Speculum Examination

• Cusco's (bivalve) - most common, self-retaining
• Sims' - L-shaped, for prolapse examination
• Pederson's - narrow, for slender/adolescent patients
• Graves' - larger, for obese or parous women

1. Warm the speculum (warm water or speculum warmer - never lubricant before Pap smear)
2. Insert at oblique angle into posterior introitus with downward pressure (away from urethra)
3. Rotate to horizontal as you advance
4. Open blades gently and identify the cervix

• Color (pink = normal; blue = Chadwick's sign of pregnancy; pale = atrophy)
• Rugosity (present in reproductive age; absent postmenopause)
• Discharge: describe amount, color, consistency, odor, lesions

• Pap smear: Use Ayre's spatula + endocervical brush
• High vaginal swab (HVS): from posterior fornix
• Endocervical swab: for chlamydia, gonorrhea

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C. Bimanual Palpation

• Feel along the vaginal walls - any tenderness, masses, nodules
• Check the fornices (anterior, posterior, lateral)

• Position: anterior (normal) / posterior (retroflexed uterus)
• Consistency: firm (normal) / soft (Hegar's sign of early pregnancy - soft isthmus)
• Os: closed / open
• Cervical Motion Tenderness (CMT): Gently move cervix side to side - sharp pain = cervical excitation = PID, ectopic pregnancy (the "chandelier sign" - patient jumps up)

• Position: anteverted/anteflexed (normal) or retroverted/retroflexed
• Size: normal (7-8 cm, pear-shaped) / enlarged (in weeks equivalent)
• Shape: regular (normal) / irregular (fibroids - lobulated masses distorting shape)
• Consistency: firm (normal) / soft (pregnancy) / hard (calcified fibroid)
• Mobility: freely mobile (normal) / fixed (adhesions, endometriosis, malignancy)
• Tenderness: none (normal) / tender (PID, endometritis)

• Normal tube: NOT palpable
• Normal ovary: 4×2×3 cm, slightly tender, mobile (sometimes palpable)
• Any adnexal mass: size, consistency, tenderness, mobility, relation to uterus
• Fullness in Pouch of Douglas (posterior fornix): fluid (ruptured ectopic, pelvic abscess), nodularity (endometriosis)

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D. Recto-vaginal Examination

• Index finger in vagina, middle finger in rectum
• Allows examination higher in the pelvis
• Check uterosacral ligaments for nodularity (endometriosis)
• Check rectal mucosa (normal = smooth)
• Essential for staging of cervical cancer and endometriosis

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E. Per Vaginum (PV) in Labor

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COMPLETE EXAMINATION ORDER - QUICK REFERENCE CARD

STAND AT THE RIGHT SIDE OF THE PATIENT

1. PREPARATION
   - Wash hands, consent, privacy, chaperone, empty bladder

2. GENERAL APPEARANCE
   - Conscious? Distressed? Built? Pallor?

3. VITAL SIGNS
   - Pulse → BP → Temp → RR → SpO2

4. PERIPHERAL EXAM (Hands → Head)
   - Hands: pallor, clubbing, koilonychia, tremor
   - Eyes: conjunctival pallor, icterus, exophthalmos, lid lag
   - Face: chloasma, acne, coarse features
   - Tongue: pallor, glossitis, cyanosis
   - Neck: thyroid, lymph nodes, JVP
   - Ankles: pitting edema

5. BREAST EXAM
   - Inspection (sitting) → Palpation (supine) → Axillary nodes

6. CVS EXAM
   - Inspect precordium + JVP
   - Palpate: apex beat, heaves, thrills
   - Percuss: cardiac borders
   - Auscultate: 5 areas with diaphragm + bell

7. RS EXAM
   - Inspect: shape, symmetry, RR, breathing pattern
   - Palpate: trachea, expansion, TVF
   - Percuss: all zones front + back (compare both sides)
   - Auscultate: breath sounds, added sounds, vocal resonance

8. ABDOMINAL EXAM
   - Inspect: shape, scars, umbilicus, skin signs
   - Palpate: superficial → deep → liver → spleen → uterus/mass
   - Fundal height (obstetric)
   - Leopold's maneuvers (obstetric, >28 weeks)
   - Percuss: dullness, shifting dullness
   - Auscultate: bowel sounds, FHR (obstetric)

9. CNS EXAM (when indicated)
   - Mental status + GCS
   - Cranial nerves (II, III-VI, VII)
   - Power + tone
   - Deep tendon reflexes (especially patellar + ankle)
   - Ankle clonus (ESSENTIAL in preeclampsia/MgSO4 monitoring)
   - Plantar reflex (Babinski)

10. PELVIC EXAM (lithotomy position, chaperone present)
    - External genitalia inspection + Valsalva
    - Speculum: vagina + cervix (Pap smear if indicated)
    - Bimanual: cervix + uterus + adnexa + POD
    - Recto-vaginal (if indicated)
    - PV in labor (if indicated)

11. COMPLETE
    - Help patient dress
    - Wash hands
    - Thank and explain findings

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"The goal of a complete examination is not to check every box - it is to understand the patient as a whole person, and to let the clinical findings guide you to a diagnosis." - Berek & Novak's Gynecology

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Metabolic Syndrome - Final Year MBBS

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1. DEFINITION

• Cardiovascular disease (CVD)
• Type 2 Diabetes Mellitus

"The metabolic syndrome consists of a constellation of metabolic abnormalities that confer increased risk of cardiovascular disease and diabetes mellitus." - Harrison's 22e (2025)

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2. HISTORICAL EVOLUTION

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3. DIAGNOSTIC CRITERIA

NCEP ATP III Criteria (Most Commonly Used in Clinical Practice)

IDF Criteria (2005) - Used in South Asian/Asian Populations

For Indian patients (most important for your exam): Use IDF criteria. Waist ≥90 cm in men, ≥80 cm in women + any 2 of the other 4 criteria.

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4. EPIDEMIOLOGY

• Prevalence in US adults: ~33-35% (NHANES data)
• Increases dramatically with age - affects nearly 50% of Americans >60 years
• Prevalence is 12-30% in obese/overweight children
• South Asians (Indians) have higher prevalence at lower BMI due to greater visceral fat deposition at any given waist circumference
• Rising globally with industrialization and sedentary lifestyles
• Women >60 years are more often affected than men of same age

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5. ETIOLOGY / RISK FACTORS

A. Overweight/Obesity

• Central/visceral adiposity is the key driver
• Even normal-weight individuals can have metabolic syndrome if they have increased visceral fat (common in Indians, Southeast Asians)

B. Sedentary Lifestyle (Harrison's 22e)

• Physical inactivity reduces cardiorespiratory fitness → increases adipose tissue, raises TG, lowers HDL, raises BP and glucose
• Watching TV/screens >4 hours/day → 2-fold increased risk of metabolic syndrome

C. Aging

• Prevalence approaches 50% in adults >60 years

D. Genetic Factors

• Heritability of each metabolic trait exceeds 50%
• Multiple genes involved (no single gene) - body weight, insulin resistance, lipid metabolism

E. Gut Microbiome

• Increased Firmicutes/Bacteroidetes ratio associated with metabolic syndrome
• Bile acid metabolism and gut-derived inflammatory signals contribute

F. Other Conditions Associated

• Polycystic ovarian syndrome (PCOS)
• Non-alcoholic fatty liver disease (NAFLD/MASLD)
• Lipodystrophy
• Chronic kidney disease
• Hypothyroidism
• Obstructive sleep apnea
• Certain drugs: antipsychotics (clozapine, olanzapine), corticosteroids, antiretrovirals

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6. PATHOPHYSIOLOGY

Central Defect: INSULIN RESISTANCE

Excess visceral adipose tissue
           ↓
↑ Free Fatty Acids (FFA) released into portal circulation
           ↓
Reach liver → ↑ VLDL synthesis → Hypertriglyceridemia
                              → ↑ apoB, ↑ Small Dense LDL (atherogenic)
           ↓
Muscle: Fat oxidation predominates → Reduced glucose uptake → Insulin resistance
           ↓
Pancreatic β-cells: Compensatory ↑ insulin secretion → eventually β-cell failure → T2DM

A. Adipose Tissue Dysfunction (Harrison's 22e)

1. Visceral fat releases FFA directly into the portal vein → liver receives high FFA load
2. Large adipocytes in obesity have excess substrate → enhanced basal lipolysis even without hormonal activation
3. Decreased perilipins (adipocyte phosphoproteins that normally protect stored TG) → enhanced unregulated lipolysis
4. Adipose tissue becomes infiltrated with macrophages → chronic low-grade inflammation → cytokines (TNF-α, IL-6) worsen insulin resistance

B. Dyslipidemia Mechanism (Harrison's 22e)

• Step 1: Insulin resistance → impaired suppression of hepatic VLDL production
• Step 2: Excess FFA from visceral fat → ↑ apo B-containing VLDL production → Hypertriglyceridemia
• Step 3: Elevated apoC-III on VLDLs → inhibits lipoprotein lipase → impairs VLDL clearance → worsens hypertriglyceridemia
• Step 4: Elevated TG + CETP (cholesteryl ester transfer protein) → exchanges TG for cholesterol in HDL → makes HDL small, dense, protein-rich → rapidly cleared from circulation → Low HDL
• Step 5: With TG >2.0 mM (180 mg/dL) → Small Dense LDL predominates → more atherogenic (penetrate endothelium more easily, more oxidizable)

C. Glucose Intolerance Mechanism (Harrison's 22e)

1. Defects in insulin action → impaired suppression of hepatic glucose production
2. Reduced glucose uptake in muscle and adipose tissue
3. Compensatory ↑ insulin secretion maintains euglycemia initially
4. Eventually β-cell secretory capacity fails → IFG → IGT → T2DM
5. High FFA levels in β-cells interfere with NADPH generation → impair insulin secretion (Basic Medical Biochemistry 6e)

D. Hypertension Mechanism

• Insulin resistance → ↑ Na⁺ retention by kidney (insulin normally promotes natriuresis)
• Sympathetic nervous system activation (FFA, leptin)
• ↑ Angiotensinogen from adipose tissue → ↑ Angiotensin II → vasoconstriction + Na⁺ retention
• Endothelial dysfunction → reduced NO → impaired vasodilation

E. Pro-inflammatory and Pro-thrombotic State

• ↑ CRP (C-reactive protein) - a marker of systemic inflammation
• ↑ IL-6, TNF-α from visceral adipocytes
• ↑ Fibrinogen, PAI-1 (plasminogen activator inhibitor-1) → impaired fibrinolysis → thrombotic tendency
• ↑ Uric acid (insulin resistance → impaired uric acid clearance)

F. Adipokines (Hormones from Fat)

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7. CLINICAL FEATURES

History

• Overweight/obese, especially central obesity
• Family history of T2DM, CVD, hypertension
• Sedentary lifestyle, high-calorie diet
• In women: PCOS (menstrual irregularity, hirsutism, acne)
• Symptoms of associated conditions: snoring/sleep apnea, fatty liver (fatigue, right upper quadrant discomfort)

Physical Examination

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8. INVESTIGATIONS

Routine Screening (ATP III)

Additional Investigations

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9. ASSOCIATED CONDITIONS AND COMPLICATIONS

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10. TREATMENT (Harrison's 22e, Chapter 420)

Step 1 - Lifestyle Modification (CORNERSTONE OF TREATMENT)

• Even 5-10% weight loss significantly improves all components
• Target: 0.5-1 kg per week

Diet

• Caloric restriction: 500-1000 kcal/day deficit
• Mediterranean diet or DASH diet - preferred
• Reduce: saturated fats, trans fats, refined carbohydrates, simple sugars (↑ VLDL production)
• Increase: fiber, whole grains, vegetables, monounsaturated fats (olive oil)
• Restrict alcohol: alcohol dramatically raises TG
• For hypertriglyceridemia: restrict dietary fat to ≤15% of calories

Physical Activity

• ≥150 min/week of moderate-intensity aerobic exercise (brisk walking, swimming, cycling)
• Aerobic exercise improves insulin sensitivity, reduces TG, raises HDL, lowers BP
• Even reducing sedentary time (screen time) has measurable benefit
• Resistance training adds benefit for insulin sensitivity

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Step 2 - Treat Individual Components

A. Dyslipidemia

B. Hypertension

• Target BP: <130/80 mmHg (ACC/AHA 2017 guidelines)
• Preferred agents in MetS:
  • ACE inhibitors / ARBs - first choice (reduce insulin resistance, protect kidney)
  • Calcium channel blockers - metabolically neutral
• Avoid (or use cautiously):
  • Beta-blockers - worsen insulin resistance, mask hypoglycemic symptoms, worsen TG, lower HDL (unless compelling indication e.g. post-MI, heart failure)
  • Thiazide diuretics (at high dose) - raise glucose, TG, uric acid; lower K⁺

C. Hyperglycemia / Prevention of T2DM

• Lifestyle is the most effective T2DM prevention (>50% reduction in progression from prediabetes)
• Metformin - drug of choice if lifestyle is insufficient:
  • Improves insulin sensitivity
  • Reduces hepatic glucose output
  • Does NOT cause weight gain (slight weight neutral or loss)
  • Reduces progression from prediabetes to T2DM by ~31%
• GLP-1 Receptor Agonists (semaglutide, liraglutide, tirzepatide): major advance in MetS
  • Promote weight loss, reduce TG, improve glycemia, reduce CV events
  • Semaglutide 2.4 mg/week → average 14.9% weight loss over 68 weeks
  • Tirzepatide (GIP + GLP-1 dual agonist) → up to 20.9% weight loss

D. Obesity Treatment (Harrison's 22e)

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Step 3 - Address Cardiovascular Risk

• ASCVD risk calculator (Pooled Cohort Equation) - calculate 10-year risk
• Aspirin: Low-dose (75-100 mg) in secondary prevention or high-risk primary prevention (discuss risk-benefit)
• Statins: High-intensity statin (atorvastatin 40-80 mg OR rosuvastatin 20-40 mg) for:
  • LDL ≥190 mg/dL at any age
  • T2DM aged 40-75 years with 10-year ASCVD risk ≥7.5%
  • Established ASCVD

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11. MONITORING

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12. EXAM SUMMARY TABLE - HIGH YIELD POINTS

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13. FREQUENTLY ASKED EXAM QUESTIONS

• WHO: Mandatory = insulin resistance/hyperglycemia + 2 others (including microalbuminuria)
• NCEP ATP III: Any 3 of 5 (no mandatory criterion; most clinical)
• IDF: Mandatory = central obesity (ethnic-specific cutoffs) + 2 others

• Asians deposit more visceral fat at any given waist circumference compared to Caucasians
• Relative visceral:subcutaneous fat ratio is higher
• Therefore lower waist cutoffs are used (90 cm men, 80 cm women in Indians)

• Homeostatic Model Assessment of Insulin Resistance
• HOMA-IR = (Fasting Insulin in µIU/mL × Fasting Glucose in mg/dL) / 405
• Normal: <2.5; IR: >2.5

• HDL normally performs reverse cholesterol transport (removes cholesterol from peripheral tissues to liver)
• In MetS: CETP exchanges HDL cholesterol for VLDL triglycerides → HDL becomes small, dense, protein-rich → rapidly cleared → low HDL → reduced reverse cholesterol transport → atherosclerosis

• For TG: Fibrates, Omega-3 FA
• For LDL: Statins (first-line), Ezetimibe, PCSK9 inhibitors
• For HTN: ACE inhibitors / ARBs preferred
• For hyperglycemia/prevention: Metformin, GLP-1 RA
• For weight: GLP-1 RA (semaglutide, liraglutide), Orlistat, Bariatric surgery

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