1.2 Comprehensive Health History & Physical Examination (Female and Male)
Key Takeaways
A complete history covers the chief complaint, medical, surgical, obstetric and gynecologic, medication (including supplements and hormones), allergy, family, social, and sexual history.
GTPAL notation counts gravidity, term births, preterm births, abortions or losses before 20 weeks, and living children; twins count as one birth event but two living children.
The bimanual exam assesses uterine size, position, contour, and mobility, cervical motion tenderness, and adnexa; the rectovaginal exam evaluates the posterior cul-de-sac, uterosacral ligaments, and rectovaginal septum.
In the male exam, a firm, painless testicular mass is cancer until proven otherwise and requires scrotal ultrasound; a varicocele feels like a 'bag of worms' and a hydrocele transilluminates.
Sudden scrotal pain with a high-riding testis and absent cremasteric reflex suggests testicular torsion, a surgical emergency.
Why History and Physical Matter on the Exam
The NCC blueprint places "Health History and Physical Examination" first in the Assessment domain (12% of the exam), and nearly every clinical vignette depends on picking out the history detail or exam finding that changes management. NCC also states that WHNP candidates are expected to examine males for reproductive health, STI, and infertility concerns.
Components of the Women's Health History
| Component | What to Elicit | Exam Pearl |
|---|---|---|
| Chief complaint / HPI | Onset, duration, character, timing relative to the menstrual cycle, associated symptoms | Relate pelvic pain and bleeding to the last menstrual period (LMP) |
| Medical history | Hypertension, diabetes, thyroid disease, VTE, migraine with aura, liver disease, cancer | Drives US MEC contraception and hormone therapy decisions |
| Medication reconciliation | Prescription, over-the-counter, herbal, hormonal, and recreational products | St. John's wort and enzyme inducers lower hormonal contraceptive levels |
| Surgical history | Cesarean, myomectomy, LEEP or cone, bariatric surgery | Prior LEEP raises preterm-birth risk; bypass surgery alters drug absorption |
| Obstetric history | GTPAL, mode of delivery, complications (preeclampsia, GDM, hemorrhage) | Adverse pregnancy outcomes are lifelong cardiovascular risk enhancers |
| Gynecologic history | Menarche, cycle length and flow, LMP, dysmenorrhea, contraception, cervical screening, STIs | Abnormal screening history sets surveillance intervals |
| Allergies | The agent and the type of reaction (rash vs anaphylaxis) | True penicillin anaphylaxis changes syphilis management in pregnancy |
| Family history | Three generations: breast, ovarian, colon, and endometrial cancer; CVD; VTE; diabetes; genetic disorders | Triggers hereditary cancer risk assessment (BRCA, Lynch) |
| Social history & health risks | Tobacco, alcohol, drugs, occupation, housing, food security, intimate partner violence | Screen for IPV privately, with the patient alone |
| Sexual history | CDC 5 Ps: partners, practices, protection from STIs, past STIs, pregnancy intention | Use gender-neutral, nonjudgmental language |
GTPAL Obstetric Notation
- G (gravida): total pregnancies, including the current one.
- T (term): births at 37 weeks or later.
- P (preterm): births from 20 0/7 to 36 6/7 weeks.
- A (abortions): pregnancy losses or terminations before 20 weeks, including ectopic pregnancy.
- L (living): children currently alive.
A multiple birth counts as one event for T or P but adds each child to L. Example: a woman who is pregnant now and has had one term birth, one twin birth at 34 weeks (both living), and one miscarriage at 9 weeks is G4 T1 P1 A1 L3.
The Female Physical Examination
- General and anthropometric: Height, weight, BMI, waist circumference (>35 inches signals central adiposity in women), and blood pressure taken with the correct cuff after 5 minutes of rest.
- HEENT and neck: Thyroid size, nodules, and tenderness; lymph nodes.
- Heart, lungs, abdomen, and extremities: Murmurs, hepatosplenomegaly, masses, edema, and varicosities.
- Breasts: Inspection in four positions and systematic palpation including the axillary tail (see the breast section).
- External genitalia: Tanner stage, hair distribution, lesions, color changes, the clitoris, the urethral meatus, Skene and Bartholin glands, and perineal integrity.
- Speculum exam: Vaginal walls (rugae, discharge, atrophy) and the cervix (ectropion, lesions, friability, os shape). Collect cytology and NAATs before lubricant contaminates the specimen.
- Bimanual exam: Uterine size (in weeks), position (anteverted or retroverted), contour, consistency, and mobility; cervical motion tenderness; adnexal size and tenderness.
- Rectovaginal exam: Index finger in the vagina and middle finger in the rectum to assess the posterior cul-de-sac, uterosacral nodularity (endometriosis), a retroverted uterus, and the rectovaginal septum. A single stool guaiac from a digital rectal exam is not adequate colorectal cancer screening.
Offer a chaperone, explain each step, and use trauma-informed techniques: let the patient control pace and stop the exam on request.
The Male Genital and Inguinal Examination
| Finding | Characteristic Features | Next Step |
|---|---|---|
| Testicular cancer | Firm, painless, nontransilluminating mass within the testis; peak age 15–35 | Scrotal ultrasound and urology referral; never aspirate |
| Varicocele | "Bag of worms" above the testis, usually left-sided, larger when standing or straining, decompresses supine | Semen analysis if infertility; a new right-sided or nondecompressing varicocele needs imaging for a retroperitoneal mass |
| Hydrocele | Smooth, cystic swelling that transilluminates | Ultrasound if the testis cannot be palpated |
| Epididymitis | Gradual posterior scrotal pain, tender epididymis, possible urethral discharge, relief with elevation (positive Prehn sign) | NAAT for gonorrhea and chlamydia; CDC regimen ceftriaxone 500 mg IM plus doxycycline 100 mg twice daily for 10 days |
| Testicular torsion | Sudden severe pain, nausea, high-riding horizontal testis, absent cremasteric reflex | Emergency surgical detorsion, ideally within 6 hours |
| Inguinal hernia | Bulge or impulse at the external ring with cough | Surgical referral; urgent if irreducible or tender |
Inspect the penis with the foreskin retracted for ulcers, warts, discharge, and meatal position, and palpate each testis between thumb and fingers. A digital rectal prostate exam is done only when symptoms or guidelines indicate it.
Documentation Pearls
Record pertinent negatives, the chaperone's presence, the patient's own words for symptoms, and consent for sensitive exams. Clear documentation supports clinical reasoning and medicolegal protection.
A woman at 10 weeks of gestation reports one prior term vaginal birth, one twin delivery at 33 weeks (both children living), and one ectopic pregnancy treated with methotrexate. Her term child is also living. What is her GTPAL notation?
G3 T1 P1 A1 L3
G4 T1 P1 A1 L3
G4 T1 P2 A1 L3
G5 T1 P2 A0 L3
A 27-year-old man, the partner of a patient receiving infertility care, reports a 'lump' in his right testicle for 3 weeks. On examination there is a firm, painless 1-cm nodule within the body of the right testis that does not transilluminate. What is the most appropriate next step?
Prescribe doxycycline for presumed epididymitis and recheck in 2 weeks.
Reassure him that this is a varicocele and order a semen analysis.
Order a scrotal ultrasound and refer him to urology.
During a pelvic examination of a 31-year-old with progressive dysmenorrhea and dyschezia, which technique best evaluates the uterosacral ligaments and rectovaginal septum for nodularity?
A rectovaginal examination with one finger in the vagina and one in the rectum
A speculum examination with acetic acid applied to the cervix and vaginal fornices
Abdominal palpation of the lower quadrants while the patient performs a Valsalva maneuver
A single-digit vaginal examination of the anterior fornix and bladder base
Sections you finish are checked off in the contents.