This document provides guidance on how to approach clinical problems by taking a thorough patient history and conducting a physical examination. It outlines the key components of the history, including the chief complaint, present and past medical histories, medications, and review of systems. The physical exam section describes examining each body system, with a focus on the pelvic exam for gynecologic cases. It emphasizes making a diagnosis, assessing severity, determining treatment, and following the patient's response.

1. How to ApproachHow to Approach
Clinical ProblemsClinical Problems

2. HISTORY
• Name.
• Age: some conditions are more common at
certain ages.
• e t c
1. Basic information

3. 3. Chief complaint
• “What brought you to the office today?”
• The chief complaint engenders a differential diagnosis,
and the possible etiologies should be explored by
further inquiry.

4. ExampleExample
• If the chief complaint is postmenopausal
bleeding, the concern is endometrial
cancer.
• Thus, some of the questions should be
related to the risk factors for endometrial
cancer (e.g. hypertension, diabetes,
anovulation, ……)

5. • The duration and character of the complaint, associated
symptoms, and exacerbating and relieving factors
should be recorded.
4. Present history

6. 5. gynecologic history
a. Menstrual history
• Age of menarche (should normally be older than 9 years
and younger than 16 years).
• Character of menstrual cycles: Interval from the first day
of one menses to the first day of the next menses
(normal is 28 ±7 days, or between 21 and 35 days), and
length of periods (number of days of bleeding)
• Quantity of menses: Menstrual flow should last less than
7 days (or be <80 mL in total volume). If menstrual flow
is excessive, then it is called menorrhagia.
• Irregular and heavy menses is called menometrorrhagia.

7. Estimation of the amount of menstrual flow can be made
by asking:
• whether the patient uses pads or tampons,
• how many are used during the heavy days of her flow,
• and whether they are soaked or just soiled when they
are changed.
It is normal for women to pass clots during menstruation,
but normally they are small.

8. • Ask about irregular bleeding (bleeding with no set
pattern or duration), intermenstrual bleeding (bleeding
between menses), or postcoital bleeding (bleeding
during or immediately after coitus).
• Ask about perimenstrual symptoms such as anxiety,
fluid retention, nervousness, mood fluctuations, food
cravings, variations in sexual feelings, and difficulty
sleeping.

9. • Cramps and discomfort during the menses are
common (menstrual pain).
• It is abnormal (dysmenorrhoea) when they
interfere with daily activities of living or when
they require more analgesia than provided by
non-narcotic analgesia.

10. • The term menopause refers to the cessation of
menses for greater than 1 year.
• Perimenopause is the time of transition from
menstrual to non-menstrual life.
• The perimenopausal period often begins with
increasing menstrual irregularity and varying
or decreased flow.

11. • Duration,
• type,
• last use of contraception, and
• any side effects.
b. Contraceptive history

12. • A positive or negative history of herpes simplex
virus, syphilis, gonorrhea, Chlamydia, human
immunodeficiencyvirus (HIV), pelvic
inflammatory disease, or human papillomavirus.
• Use of barrier contraception.
c. Sexually transmitted diseases

13. 6. Obstetric history
• Date and gestational age of each pregnancy at
termination, and outcome.
• If delivered, then whether the delivery was vaginal or
cesarean;
• If applicable, vacuum or forceps delivery, or type of
cesarean (low-transverse vs classical).
• All complications of pregnancies should be listed.

14. 7. Past medical history
• Any illnesses, such as hypertension, hepatitis, diabetes
mellitus, cancer, heart disease, pulmonary disease, and
thyroid disease should be elicited.
• Duration, severity, and therapies should be included.
• Any hospitalizations should be listed with reason for
admission, intervention, and location of hospital.

15. 8. Past surgical history
• Year and type of surgery should be elucidated and any
complications documented.
• Type of incision (laparoscopy vs laparotomy) should be
recorded.
•Reactions to medications should be recorded,
including severity and temporal relationship to
medication.
•Non-medicine allergies, such as to latex or iodine.
9. Allergies

16. 10. Medications
• A list of medications, dosage, route of administration and
frequency, and duration of use should be obtained.
• Use or abuse of illicit drugs, tobacco, or alcohol should
also be recorded

17. 11. Review of systems
• A systematic review should be performed but focused on
the more common diseases.
Example
• In pregnant women, the presence of symptoms referable
to preeclampsia, such as headache, visual disturbances,
epigastric pain, or facial swelling, should be queried.
• In an elderly woman, symptoms suggestive of cardiac
disease, such as chest pain, shortness of breath, fatigue,
weakness, or palpitations, should be elicited.

18. • In every pregnancy greater than 20 weeks’
gestation, the patient should be questioned
about symptoms of preeclampsia (headaches,
visual disturbances, dyspnea, epigastric pain,
and face/hand swelling).

19. 12.FAMILY HISTORY
• The family history should list illnesses
occurring in first-degree relatives

20. PHYSICAL EXAMINATION
1. General appearance: Cachectic versus
well-nourished, anxious versus calm, alert
versus obtunded.
2. Vital signs: Temperature, blood
pressure, heart rate, and respiratory rate.
Height and weight are often placed here
(BMI)

21. 3. Head and neck examination: e.g. goiter, cervical and
supraclavicular nodes.
4. Breast examination:
• Inspection for symmetry, skin or nipple retraction.
• Palpation systematically to assess for masses.
• The nipple should be assessed for discharge.
• The axillary and supraclavicular regions should be
examined for adenopathy.

22. 5. Cardiac examination:
• Auscultation at the apex of the heart as well as base.
• Heart sounds, murmurs, and clicks should be
characterized.
• Systolic flow murmurs are fairly common in pregnant
women due to the increased cardiac output, but
significant diastolic murmurs are unusual.
6. Pulmonary examination: The lung fields should be
examined systematically and thoroughly. Wheezes,
rales, rhonchi, and bronchial breath sounds should be
recorded

23. 7. Back and spine examination.
8. Extremities and skin.
9. Neurologic examination

24. 10. Abdominal examination:
a. Gynecologic cases:
• Inspection for scars, distension, masses or
organomegaly (ie, spleen or liver), and
discoloration.
• Auscultation of bowel sounds.
• Percussion for the presence of shifting dullness
(indicating ascites).
• Palpation to assess for masses, tenderness, and
peritoneal signs.

25. 11. Pelvic examination:
a. Gynecologic cases:
• Preparation for the pelvic examination
begins with the patient emptying her
bladder.
• Abdominal and pelvic examinations
require relaxation of the muscles.

26. Position of the patient:
• The patient should assume the lithotomy position.
• The patient should be asked to lie back, place her heels
in the stirrups, and then slide down to the end of the
table until her buttocks are flush with the edge of the
table.

27. a. The external genitalia:
• Should be observed for masses or lesions,
discoloration, redness, or tenderness.
• Ulcers in this area may indicate herpes simplex virus,
vulvar carcinoma, or syphilis.

28. • A vulvar mass at the 5:00 or 7:00 o’clock positions can
suggest a Bartholin gland cyst or abscess.
• Pigmented lesions may require biopsy since malignant
melanoma is not uncommon in the vulvar region.

29. Inspection should include the mons pubis, labia majora and
labia minora, perineum, and perianal area.
Palpation:
• The labia are spread laterally to allow inspection of the
introitus and outer vagina.
• The urethral meatus and the areas of the urethra and
Skene glands should be inspected.
• The forefinger is placed an inch or so into the vagina to
gently milk the urethra. A culture should be taken of any
discharge from the urethral opening.
• The forefinger is then rotated posteriorly to palpate the
area of the Bartholin glands between that finger and the
thumb.

31. b. Speculum examination:
• The vagina should be inspected for lesions, discharge,
estrogen effect (well-ruggated vs atrophic), and
presence of a cystocele or a rectocele.
• The appearance of the cervix should be described, and
masses, vesicles, or other lesions should be noted.

32. • The parts of the speculum :

33. • Types of vaginal specula:
Sims’ speculum
Cusco’s (bivalve) speculum

34. • Insertion of the speculum

35. c. Bimanual examination:
• The index and middle finger of the one gloved hand
should be inserted into the patient’s vagina underneath
the cervix, while the clinician’s other hand is placed on
the abdomen at the uterine fundus.
• With the uterus trapped between the two hands, the
examiner should identify whether there is cervical motion
tenderness, and evaluate the size, shape, and
directional axis of the uterus.
• The adnexa should then be assessed with the vaginal
hand in the lateral vaginal fornices.

37. d. Rectal examination:
• A rectal examination will reveal masses in the posterior
pelvis, and may identify occult blood in the stool.
• Nodularity and tenderness in the uterosacral ligament
can be signs of endometriosis.
• The posterior uterus and palpable masses in the cul-de-
sac can be identified by rectal examination.

38. e. Rectovaginal examination:

39. Approach to ClinicalApproach to Clinical
Problem SolvingProblem Solving

40. Four distinct steps
1. Making the diagnosis.
2. Assessing the severity and/or stage of the
disease.
3. Rendering a treatment based on the stage of
the disease.
4. Following the patient’s response to the
treatment.

41. Making the diagnosis
• The diagnosis is made by careful evaluation of the
database, analysis of the information, assessment of the
risk factors, and development of the list of possibilities
(the differential diagnosis).

42. • The process includes knowing which pieces of
information are meaningful and which may be thrown
out.
• Experience and knowledge help to guide the physician to
“key in” on the most important possibilities.

43. • A good clinician also knows how to ask the same
question in several different ways, and use different
terminology.
• For example, patients at times may deny having been
treated for “sexually transmitted disease,” but will answer
affirmatively to being hospitalized for “a tubal infection.”

44. • Reaching a diagnosis may be achieved by systematically
reading about each possible cause and disease.
• The patient’s presentation is then matched up against
each of these possibilities, and each is either placed high
up on the list as a potential etiology, or moved lower
down because of disease prevalence, the patient’s
presentation, or other clues.

45. • A patient’s risk factors may influence the probability of a
diagnosis.
• Usually, a long list of possible diagnoses can be pared
down to two to three most likely ones, based on selective
laboratory or imaging tests.

46. The first step in clinical problem-
solving is making the
diagnosis.

47. Assessing the severity and/or stage
of the disease.
• After ascertaining the diagnosis, the next step is to
characterize the severity of the disease process; in other
words, describe “how bad” a disease is.
• With malignancy, this is done formally by staging the
cancer.

48. • Some diseases, such as preeclampsia, may be
designated as mild or severe.
• With other diseases, there is a moderate category.

49. The second step in clinical
problem-solving is to establish the
severity or stage of disease.
There is usually prognostic or
treatment significance based on
the stage.

50. Rendering a treatment based on
the stage of the disease
• Many illnesses are stratified according to severity
because prognosis and treatment often vary based on
the severity.
• If neither the prognosis nor the treatment was influenced
by the stage of the disease process, there would not be
a reason to subcategorize a disease as mild or severe.

51. The third step in clinical problem-
solving is that, for most
conditions, the treatment is
tailored to the extent or “stage”of
the disease.

52. Following the patient’s response to
the treatment
• The fourth step in clinical problem-solving is to monitor
treatment response or efficacy, which may be measured
in different ways.
• It may be symptomatic (patient feels better), or based on
physical examination (fever), a laboratory test (CA-125
level), or an imaging test (ultrasound size of ovarian
cyst).

53. • You must be prepared to know what to do if the
measured marker does not respond according to what is
expected.
• Is the next step to retreat, or to reconsider the diagnosis,
or to repeat the metastatic work-up, or to follow up with
another more specific test?

54. Approach to ReadingApproach to Reading

55. The student should have a plan for the acquisition
and use of the information, and should read with
the goal of answering specific questions.
1. What is the most likely diagnosis?
2. What should be your next step?
3. How would you confirm the diagnosis?
4. What is the most likely mechanism for this process?
5. What are the risk factors for this condition?
6. What are the complications associated with the
disease process?
7. What is the best therapy?

56. “What is your next step?”
• Usually, the vague query, “What is your next step?” is
the most difficult question, because the answer may be
diagnostic, staging, or therapeutic.

57. WHAT ARE THE RISK FACTORS
FOR THIS PROCESS?
• Understanding the risk factors helps the practitioner to
establish a diagnosis and to determine how to interpret
tests.
• For example, understanding the risk factor analysis may
help to manage a 55-year-old woman with
postmenopausal bleeding after an endometrial biopsy
shows no pathologic changes.
• If the woman does not have any risk factors for
endometrial cancer, the patient may be observed
because the likelihood for uterine malignancy is not so
great.

58. • On the other hand, if the same 55-year-old woman was
diabetic, had a long history of anovulation (irregular
menses), was nulliparous, and hypertensive, a
practitioner should pursue the postmenopausal bleeding
further, even after a normal endometrial biopsy.
• The physician may want to perform a hysteroscopy to
visualize the endometrial cavity directly and biopsy the
abnormal-appearing areas.

59. Thus, the presence of risk factors helps to categorize the
likelihood of a disease process.
When patients are at high risk for
a disease, based on risk
factors, more testing may be
indicated.

60. WHAT ARE THE COMPLICATIONS
OF THIS PROCESS?
• Clinicians must be cognizant of the complications of a
disease, so that they will understand how to follow and
monitor the patient.

61. WHAT IS THE BEST THERAPY?
• To answer this question, the clinician needs to reach the
correct diagnosis, and assess the severity of the
condition, and then he or she must weigh the situation to
reach the appropriate intervention.

62. • For the student, knowing exact dosages is not as
important as understanding the best medication, the
route of delivery, mechanism of action, and possible
complications.
• It is important for the student to be able to verbalize the
diagnosis and the rationale for the therapy.

63. • A common error is for the student to “jump to a
treatment,” like a random guess, and, therefore, he or
she is given “right or wrong” feedback.
• In fact, the student’s guess may be correct, but for the
wrong reason; conversely, the answer may be a very
reasonable one, with only one small error in thinking.

64. • Instead, the student should verbalize the steps so that
feedback may be given at every reasoning point.
• For example, if the question is, “What is the best therapy
for a 19-year-old woman with a nontender ulcer of the
vulva and painless adenopathy who is pregnant at 12
weeks’ gestation?” the incorrect manner of response for
the student to is to blurt out “azithromycin.”

65. • Rather, the student should reason it in a way such as the
following: “The most common cause of a nontender
infectious ulcer of the vulva is syphilis. Painless
adenopathy is usually associated.
• In pregnancy, penicillin is the only effective therapy to
prevent congenital syphilis.
• Therefore, the best treatment for this woman with
probable syphilis is intramuscular penicillin (after
confirming the diagnosis).”

66. HOW WOULD YOU CONFIRM THE
DIAGNOSIS?
• The woman with a nontender vulvar ulcer is likely to
have syphilis. Confirmation can be achieved by serology
(RPR or VDRL test) and specific treponemal test.
• The student should strive to know the limitations of
various diagnostic tests, and the manifestations of
disease.

67. • however, there is a significant possibility that patients
with primary syphilis may not have developed an
antibody response yet, and have negative serology.
• Thus, confirmation of the diagnosis would be attained
with darkfield microscopy.

68. Summary
1. There is no replacement for a meticulous history and
physical examination.
2. There are four steps to the clinical approach to the
patient: making the diagnosis, assessing severity,
treating based on severity, and following response.
3. There are seven questions that help to bridge the gap
between the textbook and the clinical arena.

69. Thank you