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Thursday, September 11, 2008

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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