Infertility Flashcards
Case: A couple presented to the gyne clinic with complaints of difficulty achieving pregnancy × 3 years duration. Take a focused history from them.
- Greet examiner: good afternoon sir/ma, my name is ***, can io go ahead sir/ma
Greet patient:
G = Greet – good afternoon sir
R = Rapport – how are you doing today sir?
I = Introduce – my name is **, a candidate of the MDCN exam
P = Permission – for the purpose of this exam, I would like to take a focused history from you. Can I go ahead? - BIODATA
NASOMART:
Name – what is your name?
Age – how old are you
Sex
Occupation – where do you work?
Marital status – are you married?
Address – where do you live?
Religion – what is your religion?
Tribe – what is your tribe
If woman,
Reproductive profile – LMP, gravidity – have you even been pregnancy? Parity – do you have any children? Last child brith? - Presenting complaints – difficulty achieving pregnancy * 3 years duration ( since it’s not a symptom, doctor isn’t used, move straight to causes
- History of presenting complaints:
5 Cs (complaints, course, cause, complications, care so far)
Causes ( couples)
COUPLE:
• How long have you been married?
• How long have you been trying to conceive
• Family setting (monogamous or polygamous family setting?) – shared time with the husband, wife may meet him when not in fertile window
• Do you live together?
• How often do you have intercourse in a week? (frequency of coitus)
• Do you use protection/ Hx of use of contraceptives?
• Does your partner ejaculate into the vagina?
• Any practices before or after intercourse? (pre/post coital practices e.g. lubricants, douching) – can affect sperm motility
• Are you aware of and have intercourse during your fertile period? (time of coitus)
• Pain during intercourse (dyspareunia)
Causes ( Woman: head to toe)
• Head – headaches, blurry vision (r/o pituitary tumors)
• Neck – excessive weight gain or weight loss, heat/cold intolerance, neck swelling (r/o thyroid disorders)
• Chest – milky nipple discharge (r/o hyperprolactinemia)
o Cghin or chest hairs (r/o hirsutism – PCOS)
• Abdomen – Hx of appendicitis, typhoid perforation, peritonitis (r/o intrabdominal adhesions)
o Abdominal obesity, menstrual irregularities (r/o Cushing’s syndrome)
• Pelvis – Hx of dilation and curettage (r/o intrauterine adhesion/asherman syndrome)
o Hx of fever, vaginal discharge following D and C or delivery (r/o post abortal sepsis or puerperal sepsis)
o Hx of tubal/pelvic surgeries (r/o tubal blockage)
o Hx of lower Abd pain, vaginal discharge, fever (r/o PID)
o Vulvar itching with vaginal discharge (r/o STI)
o Hx of pelvic mass, excessive menstrual bleeds (r/o uterine fibroids)
o Hx of severe lower abdominal pain during menses (r/o endometriosis)
o Hx of irregular menses, chest/body hairs (r/o PCOS)
General factors
• Stressful lifestyle/ strenuous exercise
• Alcohol or smoking (smoking kills oocytes
• Radiation or chemotherapy
Causes ( man)
Man
• Do you have children outside marriage? (impregnate another woman?)
• Any difficulties with sexual performance (r/o erectile dysfunction)
• Hx of testicular trauma, swelling, infection (r/o testicular torsion/orchitis)
• Hx of DM, HTN
• Hx of chronic drug use (cimetidine, nitrofurantoin
• Smoke or drink alcohol
• Hx of groin surgeries – hernia repair during childhood
• Hx of radiation or chemotherapy
• Hx of childhood mumps – can lead to epididomoochitis
• Hx of STIs or Hx of purulent penile discharge, painful and frequent urination (r/o STI)
• Occupation (long distance drivers [engine towards drives side -> produces heat -> affects testes], military
• Hx of tight nylon underwear
• Hx of low sperm count/ motility
complications
complications
• Hx of depression (lack of will, social isolation, mood changes)
• Marital discord (start throwing blame at each other -> marital strain)
• Emotional stress
Care so far:
• Home remedies e.g. herbal concoctions, OTC medications etc.
• Hospitals visited
• INV done e.g hysterosalpingography (HSG), hormonal profile, seminal fluid analysis (SFA)
• Treatment received – ovulation induction with clomiphene, assisted reproductive technologies, pre-conceptional folic acid, supplements
Gyne Hx
- Menarche – at what age did you start menstruating?
- LMP?
- Flow: how many days does your period last
- Cycle length: how many days is your cycle length, or do you see your period every month?
- Dysmenorrhea – pain during menses?
- Menorrhagia: how many pads do you use per day? (>7 pads)
- Dyspareunia: painful intercourse
- Contraceptives?
- Abortion
- Pap smear?
Obstetric Hx: prenatal, peri-natal, post-natal
Prenatal/pregnancy hx:
What year?
Was pregnancy desired?
Was conception natural or assisted?
Any events during the pregnancy?
Fever and rash in early pregnancy?
Duration of the pregnancy? (how long she carried it for)
Perinatal/labor and delivery:
Mode of delivery?
If CS – why?
If vaginal: was labor spontaneous or induced?
Duration of labor?
Hx of instrumentation? E.g. vacuum, forceps
Post-natal:
Any complications like bleeding following delivery?
Sex, birth weight of baby?
Duration of hospital stay? 24 – 72hrs is normal, if more then it’s complicated most likely
Past medical and surgical history:
Hx of chronic illnesses like HTN, DM, epilepsy, asthma, SCD, PUD (HEADS, P)
Hx of similar conditions in the past
Hx of previous hospital admission, blood transfusion or surgery
Family and social history:
- Hx of chronic illnesses in family
- Hx of similar condition in mother and sisters?
- Alcohol or smoking
- Recreational drug use
Drug history
- Long term medications
- Current medications
- Drug allergies
Review of systems: head to toe
- Head: headaches, dizziness, LOC, convulsions etc.
- Eyes: blurry vision, double vision
- Nose: nose bleeds
- Mouth: mouth sores, gum bleeding
- Neck: neck swelling, excessive heat or cold, stiff neck
- Chest: diff breathing, cough, chest pain awareness of heartbeat etc.
- Abdomen: Abd pain, Abd swelling, constipation, diarrhea
- Pelvis: urinary frequency, urgency, amenorrhea, vaginal discharge etc.
- Skin: rashes, discoloration, itching etc.
- Upper limbs: limb weakness, bone pain, joint swelling/stiffness etc.
- Lower limbs: leg swelling, diff walking
