History Taking Flashcards
What additional information must be included in a gynaecological history compared to any other history?
- Sexual history
- Obstetric history
What should you not forget to ask about in a gynaecological history?
- Last menstrual period
- Cycle
- Contraception/ sexually active
- Last smear test
Give examples of specific gynaecological presenting complaints.
- Menorrhagia
- Prolapse
- Pelvic pain
- Early pregnancy bleeding
How can you judge how heavy a period is?
- How many times do you change your pad/tampon?
- Do you flood?
- What type of pad/tampon are you using?
- Why do you change your pad?
- Do you get up during the night to change your protection?
- Do you pass clots?
What may pelvic pain associated with shoulder tip pain suggest?
Ectopic pregnancy
What is involved in a gynaecological examination?
- General examination
- Abdominal examination
- PV examination
- Speculum
What is looked at on vaginal examination?
- Position of the uterus
- Size of the uterus
- Mobility of the uterus
- Adnexal masses
- Tenderness/cervical excitation
What is asked about in an obstetric history?
- Parity
- Gynaecological history
- POH
- FH for genetic history
- SH for other children
What does parity mean?
Number of pregnancies
How is parity documented?
Para A + B
(A amount of deliveries after 24 weeks and B amount of deliveries before 24 weeks including terminations and miscarriages)
What is included in the past obstetric history?
- All previous pregnancies and outcomes
- Date
- Type of delivery
- LB/SB
- Weight and sex of the baby
- Any problems encountered during pregnancy/delivery/postnatally
What is involved in the obstetric examination?
- General examination including BP
- Abdominal examination
- FH
- Urine
How is fundal height measured?
- Mother lies in semi-recumbent position with empty bladder
- Palpate the fundus with 2 hands
- Secure tape measurement down at top of fundus
- Measure to top of symphysis pubis
- Measure along longitudinal axis of measurement
How do you summarise your findings a pregnant abdomen?
- The abdomen is distended compatible with pregnancy
- The fundal height is X which is/is not in keeping with gestation
- The lie is longitudinal/oblique/transverse
- The presentation is cephalic/breech (if transverse lie then is back up/back down)
- Head is /5 palpable
- FH is heard, rate=
What does SRM stand for?
Spontaneous rupture of membranes
What does PROM stand for?
Pre-labour rupture of membranes
What does PPROM stand for?
Pre-term pre-labour rupture of membranes
What does CS stand for?
Caesarean section
What does VBAC stand for?
Vaginal delivery after caesarean
What does SVD stand for?
Spontaneous vaginal delivery
What does VE stand for?
Vaginal examination
What does PET stand for?
Pre-eclampsia
What does Mer. stand for?
Merconium
What does OA/OP/OT stand for?
Occipito-anterior
Occipito-posteriorr
Occipito-transverse
