3 - Histories and Examinations Flashcards
How do you take a gynaecological history in an emergency?
SAMPLE
How do you take an extensive gynaecological history?
https://geekymedics.com/wp-content/uploads/2020/10/OSCE-Checklist-Gynaecological-History-Taking.pdf
- HPC:
SQITARS (timing with menstruation?)
2. Impact on life/ICE
3. Gynae Symptoms and Systems Review:
PV bleeding (?IMB,?PCB,?PMB)
Abdo/Pelvic Pain, Discharge
Menstruation Hx
Vulval Itching/Skin changes
Dysparauneia
Infertility
4. PMHx
Pregnancies: Number of births/miscarriages/abortions/ectopics, means of delivery, age of child and birth weight, any delivery complications.
Cervical smear: date of the last smear, its result
Surgical history:any pelvic or abdominal surgery.
Previous gynaecological problems
Previous sexually transmitted infections
5. DHx and Allergies
Planning any pregnancies?
Contraception: Type and brand name, previous contraception history
Hormone replacement therapy: Duration, Cyclical or continuous, Combined or oestrogen-only, Method of delivery.
Recent antibiotic use: vaginal candidiasis.
Any other medications
Known allergies
6. FHx
- Breast/ovarian cancer/endometrial cancer
- Diabetes
- Bleeding disorders: menorrhagia
7. SHx
- Weight: rapid weight loss can cause oligo/amenorrhoea, obesity and cancer
- Occupation: industrial exposures
- Home situation – who is at home? Are they independent?
- Smoking and alcohol intake
- Diet and exercise
pWhat are some causes of the following types of PV bleeding:
- IM
- PC
- PM
- Intermenstrual: infection, malignancy, fibroids, endometriosis, pregnancy, and hormonal contraception
- Post-coital: cervical ectropion, infection, vaginitis, and malignancy
- Post-menopausal: malignancy, vaginal atrophy, and use of HRT
What questions do you need to ask about vaginal discharge?
- Colour
- Consistency
- Amount
- Odour
What questions do you need to ask in a menstrual history?
Frequency – average 28 days
<24 days Frequent, >38 days Infrequent
Duration – average 5 days
>8 days Prolonged, <4.5 days shortened
Volume – average 40ml menstrual blood loss over course of menses
>80ml heavy (Hb and Ferritin affected), <5ml Light
Date of last menstrual period (LMP)
If late, considerpregnancy test.
If postmenopausal, record the date of the menopause.
How do you do a systems review for a gynaecological history?
- Urinary symptoms
- Bowel symptoms
- Fever (PID)
- Fatigue (e.g. menorrhagia associated anaemia)
- Weight loss (e.g. malignancy)
- Abdominal distension (malignancy)
How do you do a bimanual examination?
Introduction: explain, chaperone, gain consent, offer to go to toilet, any pain, ?pregnant, leave to get undressed and put sheet over
Gather equipment: gloves, lubricant, towels
Abdominal Exam
Vulval Inspection: Modified lithotomy position, heels to bum and drops knees to side. Ask to cough. Look for FGM
Vaginal Exam: Ask pt if still ok to do so, lube fingers, separate labia with thumb and index of non-dominant hand, put dominant hand in laterally and then rotate upwards
Uterus: Place non-dominant hand 4cm above the pubis symphysis, place dominant hand’s fingers into the posterior fornix.
Adnexa: Palpate over left and right iliac fossa for ovaries and fallopian tubes
Inspect glove for blood or discharge
Cover the patient with the sheet, explain that the examination is now complete and provide the patient with privacy so they can get dressed. Provide paper towels for the patient to clean themselves
Further investigations suggest pelvic US and bloods
How do you do a speculum examination?
Introduction: gain consent, chaperone, pass urine, any pain, leave to get undressed
Gather equipment: gloves, lubricant, speculum, light source, paper towels
Abdominal exam and Vulval Inspection
Insert Speculum: insert sideways (blades closed, angled downwards), then rotate back 90° so that the handle is facing upwards. Open the speculum blades then tighten locking nut to fix position. Check cervix and if os is closed
Remove Speculum: Rotate backwards, thank patient and tell them they can get dressed now
What is a Sim’s speculum?
Used to assess for prolapse
How do you obtain the following swabs:
- Hi-vaginal swab
- Endocervical charcoal media swab
- Endocervical chlamydia swab
- Hi-vaginal swab – circle around high vaginal wall once (BV, TV, Candida, group B strep)
- Endocervical charcoal media swab – place in endocervical canal and do a 360-degree sweep (gonorrhoea)
- Endocervical chlamydia swab – scrub endocervical region for 10-30 seconds
How do you do a smear once the speculum is in?
- Pass the cytobrush into the endocervical canal
- Turn the brush 360 degrees 5 times
- Put brush in specimen pot and move against the bottom of the pot to dislodge cells into the liquid
- Label the specimen and send it off for liquid based cytology
How do you take an obstetric history? (WATCH YOUTUBE VIDEO)
- Introduction and Gain consent
- PC and HPC (SQITARS)
- Focused Obstetric Symptoms: N+V, Reduced FM, PV bleeding, PV discharge, Abdominal Pain, Headache, Visual Disturbance, Pruitis, Chest pain, SOB, Fever
- ICE
- Gestational Age: scan results, screening results if opted for them, did they take folic acid, planned mode of delivery, any medical illness, immunisation history, mental health history
- Previous Obstetric History: gravidity, parity, gestation at delivery, mode of delivery, birth weight, any complications, any IVF, any stillbirths, any miscarriage, any TOP and how, any ectopics and how managed
- Gynae History: cervical screening, previous STIs, any other gynaecological condition
- PMHx and Allergies
- DHx
- FHx inc genetic diseases, pre-eclampsia and T2DM
- SHx inc recreational drug use and maternity leave
- DOMESTIC ABUSE
What things are included in a routine antenatal check?
- BP
- Urinalysis
- Obstetric abdominal palpation
How do you perform an obstetric examination?
- Introduce, gain consent, any pain, would you like to pass urine?
- Gather Pinnard’s and Measuring tape
- Position bed at 30 degree angle and expose: pubic symphysis to xiphisternum
- Inspect: distended, jaundice, pallor, scars, oedema, linea nigra, striae gravidarum, any fetal movements
- Symphysis Fundal Height: check if done in last 2/52 first
- Palpation: top of uterus, lie of baby, presentation of baby, engaged in fifths
- Ausculation: between shoulders of baby, take hands away from stethoscope, palpate mother’s radial pulse at same time
- Thank patient and summarise
How is an amniocentesis carried out?
Used to obtain amniotic fluid containing fetal cells
- Local anaesthetic to mother
- US guidance used to put needle through mother’s abdomen to amniotic fluid. Do not puncture placenta
- Send fluid for karyotyping and PCR
- Give anti-D immunoglobulin if Rhesus negative
When is amniocentesis carried out?
Usually if over 15 weeks gestation
High risk result on first trimester screening for chromosomal abnormalities or previous pregnancy with genetic/chromosomal abnormalities
What are the complications with amniocentesis?
- 1% risk of miscarriage: higher if performed before 14 weeks gestation.
- False reassurance
- Risk of infection
- Pain
- Rhesus sensitisation
- Increased risk of club foot
How is Chorionic Villus Sampling carried out?
Done earlier than amniocentesis and results back quicker. Can also be used for autosomal dominant and recessive genetic conditions
Done either transabdominal (more common) or transcervical to get placental biopsy
Local anaesthetic either by US guided transabdominal needle or US-guided transcervical cannula aspiration or biopsy forceps
If rhesus D negative give anti-D immunoglobulin
If a woman has a high risk screening result on anomaly scan, what information do you need to give them?
- Not a diagnosis, need diagnostic tests for that
- Risks of CVS and aminocentesis
- Inform them they don’t have to have diagnostic tests if they don’t want to
What are the benefits of CVS over amniocentesis?
- Can get chromosomal results back after 48 hours so more time to make decisions
- Done earlier in pregnancy
- Disadvantage: lower accuracy than amniocentesis due to placental mosaicism
What are the complications with CVS?
- Miscarriage: additional risk of 1% following chorionic villus sampling, slightly higher than amniocentesis but this procedure is done at gestation where spontaneous miscarriage more common
- Vaginal bleeding: higher in transcervical approach
- Pain
- Infection
- Amniotic fluid leakage
- Resus sensitisation
- 1% risk of mosaic result: Amniocentesis may then be offered to establish whether baby has a mosaic karyotype or just placenta
What are the risks and benefits of an aspiration for a miscarriage?
https://mft.nhs.uk/app/uploads/sites/4/2018/04/02-83-Choices-of-management-for-a-miscarriage-June-2018.pdf
SEE ATTACHED LINK
Risks
- Infection
- Endometritis can lead to Asherman’s and future ectopics
- Perforation to bowel/bladder
Benefits
- Faster
- If molar pregnancy helps ensure no retained products
- 95% successful
What are the advantages and disadvantages of each management option for a miscarriage?
https://mft.nhs.uk/app/uploads/sites/4/2018/04/02-83-Choices-of-management-for-a-miscarriage-June-2018.pdf
How do you take a sexual history from a male?
- Introduce and Gain consent: ‘I’m going to have to ask some personal questions’ and affirm confidentiality
2. PC
3. Key Symptoms: testicular pain or swelling, discharge, dysuria, skin lesions/changes
4. Sexual Contact: Give a warning, When, Relationship to person, Sex and Country of Origin of person, Type of Sex, Contraception, Other partners in last 3 months
5. HIV risk assessment
6. PMHx and Surgical Hx: including previous STIs and immunisations for hepatitis
7. Drugs and Allergies
8. SHx: alcohol, smoking, recreational drug use, occupation
9. Close consultation and reaffirm confidentiality
How do you do a BBV risk assessment in a sexual health history?
- “Have you ever had a partner who is known to be HIV positive?”
- “Have you ever had sex with a bisexual man/engaged in male homosexual activity?”
- “Have you ever had sex with someone abroad, or who was born in a different country?”
- “Have you ever injected drugs?”
- “Are you aware of any of your previous partners having ever injected drugs?”
- “Have you ever paid someone for sex, or been paid for sex?”
What can you stay at the start of a sexual history to build a rapport with somebody?
- Warn them
- Confidentiality
How do you take a sexual history from a female?
- Introduce and Gain consent: ‘I’m going to have to ask some personal questions’ and affirm confidentiality
2. PC: SQITARS and ICE
3. Key Symptoms: Abdominal/Pelvic Pain, dysparauniea, discharge, PCB, ICB, PMB, Skin changes and itching, Systemic symptoms
4. Menstrual Hx: Duration, Length, Volume
4. Past gynae Hx: procedures and disease
4. Cervical Screening: When, results, vaccine
4. Past Obstetric Hx
4. Contraception
4. Sexual Contact: Give a warning, When, Relationship to person, Sex and Country of Origin of person, Type of Sex, Contraception, Other partners in last 3 months
5. HIV risk assessment
6. PMHx and Surgical Hx: including previous STIs and immunisations for hepatitis
7. Drugs and Allergies
8. SHx: alcohol, smoking, recreational drug use, occupation
9. Close consultation and reaffirm confidentiality
How can you take a contraceptive history from a woman?
- Age
- Relationship
- Previous contraception tried
- Menstrual Hx
- Gynae Hx
- Obs Hx
- PMHx inc Migraine with aura, DVT, previous STIs
- DHx and Allergies
- SHx inc smoking and drinking
- FHx inc breast cancer, cervical cancer VTE
- Any preference
How do you take a focused sexual history?
5 Ps
Partner: How many, Gender, Country of origin
Practices: Oral, Vaginal, Anal, Top or Bottom, Paid sex, Any partners used IV drugs
Protection: Contraception, When is it used and not used, Hep and HPV vaccines
Past STIs
Pregnancy Intention
How do you perform a male testicular and penile examination?
- Introduce, Gain Consent, Chaperone: Any pain? Provide privacy to undress
2. Inspect: Abdomen, Groin, Penis, Foreskin, Scrotum and Perineum. Look for skin changes, masses, scars, necrotic tissue
3. Penis: Retract foreskin, open urethral meatus, inspect glans, replace foreskin to prevent paraphimosis
4. Testicles: Start with normal one, palpate whole, feel epididymis on posterior, spermatic cord at superior,
5. Prehn’s Test: if relieved on elevation then likely epididymitis
6. Cremasteric Reflex: absent in torsion, also suggest Doppler to rule out
7. Ask patient to stand and look at testicles for hernia and varicocele
- Thank pt and suggest further tests: Abdo, DRE, US Doppler
