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SpC O&G > O&G History Taking + P/E > Flashcards

O&G History Taking + P/E Flashcards

1
Q

***Obstetric History Taking

A
  1. Background
    - Occupation
    - Referred from
  2. Chief complaint
  3. History of present illness
    - Presenting symptom
    - Associated symptoms
    - **Symptoms of pregnancy: N+V, GERD, Constipation, Urinary frequency, Back pain, Leg cramps, Carpal tunnel syndrome etc.
    - **    Symptoms of labour: Abdominal pain, Leaking (Blood / Meconium stained), Show
    - **Fetal movements
    - **    Vaginal bleeding (Provocative factors: **Trauma, **Coitus, Amount) / discharge
    - Fever, Urinary / Bowel symptoms
  4. **History of present pregnancy
    Conception:
    - **    Planned / Unplanned
    - **Wanted / Unwanted
    - **    Mode of conception: Natural / Assisted
    - **LMP + Expected date of confinement (EDC)
    —> Date of 1st positive pregnancy test
    —> Establish reliability of LMP by: Cycle details, Any early USG
    —> EDC: 40 weeks after LMP (add 9 months + 7 days)
    - **    Current gestation (by Date / USG)
    - **Previous AN care (MCH, private etc.) —> Any **complications
    - Expected mode of delivery

Mother Screening:
- BP, Blood tests, Urinalysis
- Cervical smear
- **Early OGTT (if indicated)
- **Routine OGTT
- ***GBS screening

Fetal screening:
- **Dating scan
- **Down syndrome screening (Nuchal translucency, Biochemical tests, NIPT)
- **Antenatal blood tests (Hb, MCV, Rh, Blood group, Hep B, HIV, VDRL, Rubella)
- **Morphology scan
- Other additional tests

  1. Obstetric history
    - Gravidity
    - Parity
    - Details (**記: Antenatal, Intrapartum, Postpartum)
    —> **    Antenatal complications
    —> **Date
    —> **    Gestation of delivery
    —> **Mode of delivery + **Instrumental / **Operative delivery (if C-section —> any contraindication for VBAC)
    —> **    Outcome / Complications
    —> **History of IUGR, Pre-eclampsia, Neonatal death (NND)
    —> Birthweight
    —> Problems in pregnancy / labour
    —> **    Postnatal complications
    —> Puerperal problems
  2. Gynaecological history
    - ***Cervical smear (Date + Result)
  3. **Menstrual history
    - Menarche, Menopause
    - Period
    —> Duration
    —> Cycle length
    —> Regular / Irregular
    —> Flow (Clot, Flooding sensation)
    —> Dysmenorrhoea
    —> IMP + PCB
    —> **    LMP + ***PMP
    —> Postmenopausal bleeding
    —> Menopausal symptoms (e.g. hot flushes, sweating)
    —> Anaemic symptoms
  4. Sexual history
    - Contraception
    - Dyspareunia
    - Pregnancy
    - Post-coital bleeding
  5. Marital history
    - Married / Single / Divorced / Widowed
    - Married for how many years
    - Infertility
    - Husband occupation, age, health
    - Consanguinity
  6. Past medical history
    - Drug allergy
    - History of chicken pox / vaccination
    - History of measles / vaccination
    - History of vaginal infections (Group B Strept)
    - History of STD
    - History of infertility
  7. Past surgical history
    - Adhesions
  8. Social history
    - Smoking, Drinking, Drug abuse
    - Jehovah’s Witness
  9. Family history
    - ***Family history of DM
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2
Q

***Obstetric P/E

A
  1. General examination
    - Height, Weight, BMI
    - BP (5th Korotkoff sound for DBP, 140/90 cut-off for HT), Pulse
    - ***Urine protein + sugar (hyperestrogenic state of pregnancy may increase vaginal discharge —> apparent proteinuria —> use MSU)
    - Temp
    - Pallor
    - Ankle edema
    - LN
  2. Systemic examination
    - Thyroid
    - CVS
    - Respiratory
    - Breast
  3. Abdominal examination
    - Inspection:
    —> **Scar
    —> **    Striae gravidarum
    —> **Linea nigra (increased melanocyte-stimulating hormone made by placenta)
    —> **    Umbilicus (everted)
    —> **Fetal movement
    —> **    Size of uterus
  • Palpation:
    —> **Uterine size, tenderness, mass
    —> **    Symphysio-fundal height
    (記: **PLPEL)
    —> **    Fetal poles: Singleton / Multiple
    —> **Lie (Longitudinal / Oblique / Transverse) —> determine fetal back and help placement of stethoscope
    —> **    Presentation (Cephalic / Breech)
    —> **Engagement
    —> **    Liquor volume (Polyhydramnios —> cannot palpate fetal parts, Oligohydramnios —> fetal parts easily palpable)
  • Auscultation: Fetal heart (use Fetal Doppler / Stethoscope) (Auscultate at **anterior shoulder (shoulder of fetus that faces pubic symphysis, near cephalic end of back): normal fetal HR: **110-160)
  1. PV examination
    - Vulva
    - Vagina
    - Cervix
    - Uterus
    - Fornices
  2. PR examination
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3
Q

Symphysio-fundal height (SFH)

A
  • Upper border of pubic symphysis to Fundus
  • Fundus: level when resistance first met during moving down of hand
  • SFH: Estimation of fetal size —> 1cm per week after mid 2nd trimester
  • Tape upside down to prevent bias

Conditions that may affect SFH (+ SpC Revision):
1. Fetal head engagement
- may shorten SFH —> Symphysio-fundal height growth chart (adjusted for gestation)
2. Fetal Lie
3. Number of fetus
4. Liquor volume
5. Thick maternal abdomen
6. Uterine fibroid, Full bladder, Ovarian cyst

Usual landmarks:
1. 12 weeks —> Fundus just palpable above pubic symphysis
2. 20 weeks —> Umbilicus
3. 36 weeks —> Xiphisternum
4. 40 weeks —> Come down again due to engagement

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4
Q

Engagement

A
  • When largest presenting part (e.g. head) has entered pelvic brim
  • Cephalic presentation: Largest diameter usually **biparietal diameter / **suboccipitobregmatic diameter
  • 2/5 palpable in abdomen —> Engaged
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5
Q

Antenatal care

A

Objectives:
1. Detect correctable abnormalities of mother + fetus
2. Institute timely + appropriate treatment
3. Offer emotional support

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6
Q

Obstetric investigations

A
  1. Hb, MCV
  2. Rh
  3. Red cell Ab (blood group)
  4. Platelet
  5. HBsAg
  6. Rubella
  7. VDRL
  8. HIV
  9. USG exam (e.g. Dating scan, Down screening, Morphology)
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7
Q

Systems for antenatal care

A
  1. Exclusive hospital (specialist) care
    - reserved for high risk pregnancies
  2. Primary health care based with referral to specialist only when indicated
    - GP / Midwives
  3. Shared care (between hospital and primary health care)
  4. Outreach
    - usually by trained but not medically qualified persons
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8
Q

***Gynaecology History Taking

A
  1. Background
    - Occupation
    - Referred from
  2. Chief complaint
  3. History of present illness
    - Presenting symptom
    - Associated symptoms
    —> Abdominal pain
    —> Fever, Bleeding, Discharge
    —> Urinary / Bowel symptoms
    —> Pressure symptoms
    —> Constitutional symptoms
  4. **Menstrual history
    - **    Menarche, **Menopause
    - Period
    —> **    Duration
    —> **Cycle length
    —> **    Regular / Irregular
    —> **Flow (Clot, Flooding sensation)
    —> **    Dysmenorrhoea
    —> **IMP + **PCB
    —> **LMP + **PMP
    —> ***Postmenopausal bleeding
    —> Menopausal symptoms (e.g. hot flushes, sweating)
    —> Anaemic symptoms
  5. Gynaecological history
    - ***Cervical smear (Date + Result)
  6. Obstetric history
    - Gravidity
    - Parity
    - Details (***記: Antenatal, Intrapartum, Postpartum)
    —> Antenatal complications
    —> Date
    —> Gestation of delivery
    —> Mode of delivery + Instrumental / Operative delivery (if C-section —> any contraindication for VBAC)
    —> Outcome / Complications
    —> History of IUGR, Pre-eclampsia, Neonatal death (NND)
    —> Birthweight
    —> Problems in pregnancy / labour
    —> Postnatal complications
    —> Puerperal problems
  7. Sexual history
    - Contraception
    - Dyspareunia
    - Pregnancy
    - Post-coital bleeding
  8. Marital history
    - Married / Single / Divorced / Widowed
    - Married for how many years
    - Infertility
    - Husband occupation, age, health
    - Consanguinity
  9. Past medical history
    - Drug allergy
    - History of vaginal infections (Group B Strept)
    - History of STD
    - History of infertility
  10. Past surgical history
    - Adhesions
  11. Social history
    - Smoking, Drinking, Drug abuse
    - Jehovah’s Witness
  12. Family history
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9
Q

***Gynaecology P/E

A

Ask background information before examination:
- Any particular gynaecological problems
- Any discomfort now
- LMP
- Marital status
- Sexual history
- Contraception
- Previous gynae exam

  1. General examination
    - Height, Weight, BMI
    - BP (5th Korotkoff sound for DBP, 140/90 cut-off for HT), Pulse
    - Temp
    - Pallor
    - Ankle edema
    - LN
  2. Systemic examination
    - Thyroid
    - CVS
    - Respiratory
    - Breast
  3. Abdominal examination
    - Inspection: Scars, Distension
    - Palpate (From above **downwards): Tenderness, Peritoneal signs, Mass, Groin LN, **Uterine size (describe by ***Gestational size (e.g. 12-week size))
    - Percuss: Shifting dullness
    - Auscultate: Bowel sounds

Pelvic examination (盆腔檢查)
4. PV examination (Vulva, Vagina, Cervix, Uterus, Fornices)
Inspection:
- **External genitalia: skin lesions, scar, hair distribution
- **Vulva (Labia majora + minor + Clitoris): swelling, inflammation, ulceration, atrophy
- **Urethra: urethritis, caruncle
- **Perineum
- Prolapse

Speculum examination:
- Direct vision of **vagina + **cervix
- **Cervical smear
- High vaginal / endocervical swab (for C+S)
- Lithotomy / Left lateral
- Bivalve speculum (Cusco’s) / Sims’ speculum
- Correct size
—> Part labia avoiding touching clitoris
—> 45o toward floor
—> Rotate near introitus while inserting (NOT turn when speculum already inside vagina)
—> Open blade gently until **cervix seen
—> **Cervical smear (5 turns —> put in medium —> discard cervix brush)
—> Inspect **vaginal walls while withdrawing speculum

**Bimanual examination:
- Look at **Vaginal wall
- Palpate **Cervix for consistency + **cervical excitation
- Palpate **Uterus for size, direction, shape, mobility, consistency, tenderness, tumour
- Palpate **Lateral fornices for enlargement / tenderness of Fallopian tubes + Ovaries
- Palpate **Posterior fornix for swelling / tenderness in PoD
- Palpate **Anterior fornix for swelling / tenderness
- ***Withdraw fingers for bleeding / discharge
- Lithotomy / Left lateral

  1. PR examination
    - **Retroverted uterus / swelling in PoD
    - **    Parametria for thickening
    - ***Rectal tumour
    - Bimanual examination of Uterus, Fallopian tubes, Ovaries when vaginal examination impossible / undesirable (e.g. sexually inactive women)
  2. Rectovaginal examination
    - **Posterior surface of Uterus, **Broad ligament, **Uterosacral ligament, **Rectovaginal septum for nodularity, tenderness, abnormalities
    - Index finger in vagina, Middle finger in rectum
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10
Q

Equipments for Gynaecology P/E

A
  1. Speculum
    - Cusco’s
    - Sims (pull anterior to see posterior vaginal wall / pull posterior to see anterior vaginal wall)
  2. Polypectomy forceps / Ring forceps / Sponge forceps
    - Avulsion of polyps by twisting
  3. Single-tooth / Double-tooth vulsellum
    - Clamp anterior lip of cervix to straighten cervix for endometrial aspiration
  4. Hegar dilator
    - Dilate cervix
  5. Cervix brush
  6. Endometrial sampler
    - Inserted into uterine cavity —> pull backwards to generate vacuum —> suck endometrial tissue into tube —> push tissue into formalin bottle for histology
  7. Uterine sound
    - Determine length of uterine cavity
  8. Uterine curette
    - Obtain endometrial sampling
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11
Q

Template for P/E findings

A
  1. General examination
    - BP 120/80 mmHg, Pulse 80/min regular
    - Temp: 36.9oC
    - BW: 56, Height 162, BMI 21.3
    - General condition: Well
  2. Systemic examination
    - Thyroid: Normal
    - Breasts: Normal
    - CVS system: Normal
    - Respiratory system: Normal
  3. Abdominal examination
    - Abdomen: Soft, Non-tender, No scar, No mass, No groin LN
  4. PV examination (Inspection + Speculum + Bimanual)
    - Vulva: Normal, No local lesion
    - Vagina: Normal, No abnormal discharge, No blood
    - Cervix: Normal, No local lesion, No excitation tenderness
    - Uterus: Normal-sized, Anteverted, Regular, Mobile
    - Adnexae: No mass, Non-tender, (Fornices clear (SpC OG))
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SpC O&G (12 decks)

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