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History Taking and Physical EHISTORY EXAMINATION OF

GYNECOLOGY AND OBSTETRICS PATIENTS

xamination in Obstetrics and Gynaecology


Name Age Nationality Occupation Gravidity and parity: LMP EDD Naegles 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 Husbands 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 p osition for delivery. It also tells whether the babys back is on the right or left.75% of babys 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 babys 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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