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Thread: History Taking and Physical Examination in Obstetrics and Gynaecology

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    Default History Taking and Physical Examination in Obstetrics and Gynaecology



    History Taking and Physical Examination in Obstetrics and Gynaecology

    Name
    Age
    Nationality
    Occupation
    Gravidity and parity:
    LMP
    EDD


    Naegle’s rule:

    EDD= LMP + 7d – 3 mths (or + 9 mths)
    Pregnancy wheel may be used

    How many weeks pregnant now
    (gravida#, para#, +abortions)
    delivery of twins or triplets is considered one parity; eg. 2 sets of twins is para2, although she has 4 children.

    Any delivery <28weeks>28weeks is para

    Ectopic pregnancy is mentioned extra

    When first fetal movements were felt(quickening, in a primi gravida around 18-20/52, in multipara 16-18/52

    Chief complaint, and present pregnancy

    Admitted through OPD/ER on the date complaining of eg. Morning sickness, bleeding PV, abdominal pain…

    Menstrual History


    Menarche: age average 12-13 years
    Cycle days/ interval from first day to first day of next period, regularity
    Most perfect is 4-7/28 regular (but only 10% of population)
    Amount of flow: tampons or pads staining, important b/c may indicate fibroids or endometrial polyps if too heavy.
    Dysmenorrhea: (primary d/t narrow cervical canal and heavy contraction, or secondary d/t endometriosis)
    Any intermenstrual bleeding
    LMP: make sure you specifically ask about the first day of the cycle


    Sexual and contraceptive history:
    Frequency
    Any discomfort or pain
    Contraception by an IUD, condoms, OCP

    Obstetric history:

    Birth:
    Year
    FTND (full term normal delivery); vaginal/C-section
    Born home/hospital
    Male/female baby
    Weight (healthy at 2.8-3.6 kg, >4kg is macrosomic usu d/t DM or genetic. Macrosomic babies suffer risk during delivery b/c more chances of injuring the clavicles. C-section is preferred, but not routine)
    PP complications
    Breast fed
    Baby alive and well
    Ex. 1989, FTND, in hospital, male baby, 3.5 kg, no PP complications, breast fed

    Complicated birth:

    Year
    39/52
    C.S for APH
    Male/female
    Alive
    Weight
    Post-op normal
    Breast fed
    Ex. 1986, C.S for APH, female baby alive 3kg, post op normal, breast fed

    Abortion:
    Year
    Gestational age (eg. at 10/52)
    Evacuation
    Post Op complications
    Ex. 1990, abortion at 10/52, evac, no post op complications
    Ex.2: 1992, abortion at 22/52, D&E, no post op complications

    Past medical & surgical history:


    Especially surgeries on the uterus; myomectomy removal of fibroids
    Hx of infertility
    Hx of abdominal surgery may cause adhesions

    Family history:


    HTN
    DM
    epilepsy
    twins
    TB
    Malformations
    Infertility

    Social history:

    House wife/ working mother
    Smoking; ask about shisha as well
    Drinking
    Husband’s profession

    Drug and allergy history:

    OCP
    Teratogenic drugs; OHA, phenytoin, cytotoxic drugs, tetracycline, chloramphenicol..

    Detailed history of the present complaint:

    Abnormal menstrual loss:

    pattern, regular/ irregular
    Amount of loss
    # of pads or tampons used
    passage of clots or flooding
    any pain with the loss

    Pelvic pain:
    Site, Nature, Relation to periods, Aggravating and relieving factors, associated SS

    Vaginal discharge:
    Amount, color, odor, blood, rash, pain

    Micturation and bowel:


    Frequency of micturation increase d/t pressure and irritation. Urine retention is d/t the effect of progesterone which relaxes the bladder muscles , and the rectum muscles leading to incomplete emptying of the bladder and constipation. A high fiber diet is suggested and laxatives may be prescribed.
    Ask about: incontinence (real or stress), urgency, dysurea, hematurea
    Loin to groin pain

    Vaginal discharge and bleeding:


    Physical examination of OB-GYNE


    General:

    Appearance: ill/well, obese/thin, anxious/ depressed
    Pallor
    Jaundice
    Cyanosis
    Edema
    Pigmentation
    Varicose veins, ulcers

    Vital signs:

    Pulse
    BP
    Temp
    RR
    Urine dip stick for protein and sugar

    Systemic review:


    Respiratory system
    CVS
    Breasts, and other systems

    ABDOMINAL EXAMINATION:


    Inspection:
    striae, kicking, bulges
    size and shape:
    midline fullness indicates ovarian or uterine mass. Fullness of flanks suggests ascites (confirm by fluid thrill and shifting dullness), iliac fossa masses usually ovarian or bowel.
    linea albicans/nigra, rash, pigmentation

    Palpation:

    Rigidity or guarding

    Mass: position, size, shape, edges, mobility, consistency, fluid thrill if cystic

    Malignant tumors usually fixed. Mobile tumors usually benign, but may be fixed by adhesions.

    The Fundus

    Fundal height:

    from S.pubis uptil the fundus. If by calculation 38 and measure 26 it means there is either a miscalculation of the EDD, or a problem with the fetus as IUGR. Also if the opposite, the calculation, it may suggest a macrosomic baby, twin pregnancy, polyhydramnios, hydropis fetalis.

    Fundal grip:

    to see whether the head or the buttocks are occupying the fundus.
    Cephalic presentation
    when the head is down and the buttocks occupy the fundus.
    Breech presentation
    is when the head occupies the fundus. This is significant esp in a primigravida where C-section is preferred.

    Lateral grip:

    important to assess how the baby is lying; whether transverse, oblique or longitudinal, the latter being the only ideal position for delivery. It also tells whether the baby’s back is on the right or left.75% of baby’s backs are on the left probably b/c of the liver on the right. This is necessary to find the site to auscultate for the baby’s heart beat.

    First pelvic grip:

    The only position with the back to the patient
    Insert the fingers into the pelvis to see what part of the baby occupies the pelvis

    Second pelvic grip:
    Move the part left and right , if mobile, then it is not in the pelvic brim, so no engagement has occurred yet. If immobile it means that the BPD (biparietal diameter) of the baby is in the pelvic brim; i.e engagement occurred. This palpation is necessary esp in primigravida b/c if 36 weeks passed and no engagement occurred, it may suggest that the pelvis is too narrow, or the baby has hydrocephalus etc..

    Percussion:

    Dull masses are in sontact with the abdominal wall, while resonant suggest being behind the bowel

    Auscultation:

    Bowel sounds, absent in ileus
    Fetal heart: heard with stethoscope after 24/52, with portable sonicaide at 12/52

    PELVIC EXAMINATION:

    Bladder must be empty

    More in Gyne cases

    Normal anatomy
    Vulva, Labia majora, labia minora,Clitoris
    Look for ulcers, inflammation, growths or swellings
    Inspect urethral orifice for discharge ( if present spread on thin film), redness or growth

    Speculum to assess vagina: Sims speculum, Cusco

    Digital: use lubricant, left hand spreads labia insert right hand: palpate vaginal walls, growth, cyst, FB. Then examine fornices check for obliteration or swelling. Cervix is examined next noting direction, size and shape, surface smooth/irregular, size of external os, and growths or ulcerations
    Bimanual: right inserted and left pushing on abdomen; to feel uterus ( if retroverted will not be felt unless put fingers to posterior fornex). Determine size, mobility, and surrounding structure. Only abnormal fallopian tubes are palpable. Ovaries may be felt as small mobile oval structures that are sensitive to pressure

    Positions:
    - Left lateral
    - Sims Semi-prone: good for external genitalia, Cervix and anterior vaginal wall, exposing the vaginal end of the vesicovagianl fistula
    - Dorsal: good for vulva, bimanual, most frequently use
    - Lithotomy: best position for under anesthesia examination

    Rectal examination:

    Done in virgins, when PV is difficult

    PAP smear:

    R/O CIN cervical intraepithelial neoplasia

    ULTRA SOUND:
    Useful but not available every where
    - measures the BPD
    - measures the femoral length
    this is accurate in the first 16 weeks. After 16 weeks it has a +/- 2 weeks accuracy

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    thanks a lot...it will be helpful for me as my posting in gynae is in next month




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    Welcome

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    Default Re: History Taking and Physical Examination in Obstetrics and Gynaecology

    you guys are great..thankyou soooooo much

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    Default Re: History Taking and Physical Examination in Obstetrics and Gynaecology

    it's an amaaaazing information
    thanks you doc it will help me a loo0o0ot in my current shift .

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    Default Re: History Taking and Physical Examination in Obstetrics and Gynaecology

    thanks

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    Default Re: History Taking and Physical Examination in Obstetrics and Gynaecology


    Thats quite concise and useful. Thank you v much

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