Vaginal Prolapse Flashcards
A 30 year old woman presents with complains of protruding mass from her vaginal and lower back pain. There’s no history or weIgnt loss, excessive nignt sweats or change in appetite Take a focused history from her to get the possible diagnosis.
GRIP
Greet - Good morning Sir/ Ma( examiner) … Good morning MA
Rapport: how are you doing today
Introduce: my name is “ insert name “ a candidate of the ongoing mdcn exam. for the purpose of the exams I have been asked to take a focused history from you. Or I been asked to ask you some questions
•permission: please May proceed
2) BIODATA [NASOMARTI
Name: what is vour name
Ade : now old are vou
Sex: __
Occupation: what do you do for a living
Address: where do you live
Religion: what religion do you practice
Tribe: what tribe are you
Reproductive profile: when was the First day or your last menstrual period? Have you ever been pregnant ? when was your last child born.
It states her that you presented with protruding mass and back pain. I’m I right? Which one started first?
HISTORY OF PRESENTING COMPLAIN
Protruding mass from the vagina { DOCTOR}
Duration: how long have you noticed this mass
Onset: DId It start suddenly or gradually
Character course: has it gotten worse over time or better
Does it reduce on its own, or do you have to push it back?.
it is painful to touch? It hard/firm/mobile or soft ?
Time: is it worse at any particular time of the day or after any particular activity
Other svmptoms: an abnormal discharge or bleeding
Related phenomenon
• Is It worsened on coughing, standing or straining. Any leakage of fluid or urine
Lower back pain [SOCRATES]
Site: where do you feel this pain
Onset: did it start suddenly or gradually
Course/Character: is the pain getting worse or better
Is it a dull / sharp/ stabbing or burning pain
Radiation: does the pain radiate to any other part of your body
Alleviating Factors : Is there anthing you do to make the pain better
Time: is the pain worse at any time of the day or following any activity
Exacerbating : is There something that makes the pain worsen
On a scale of 1 to 10 can you characterize this pain
CAUSES
1) Childbirth: have you been pregnant before ?
how many children have you had ?
did you have any history of prolonged labor.
Did you have an instrument used in any of your deliveries
2) Menopause: When was your last menstrual period
3) Chronic cough: have you been coughing for a long time? have you been having recurrent cough?
4) heavy lifting : what work do you do? Does your work require you carrying heavy load
5) Obesity : do you know your weight? Do you usually eat fatty foods?
6) Pelvic surgeries: have you had any surgeries done on your pelvic region or have you had any recent trauma to your pelvic region
7) Connective tissue disease: any history of similar condition in your family.
any history of syndromes like the marfan’s syndrome
8) Chronic constipation: have you straining to pass stool, or have you been having recurrent constipation
COMPLICATIONS
1) Urinary tract infections: since this started have you noticed recurrent infections or abnormal discharge
2) Urine incontinence: have you noticed leakage of urine during activities like sneezing or coughing
3) Bowel issues: have you noticed difficulty passing stool or has this caused to stool on yourself
4) Ulceration: have you noticed any wound on the protruding mass. has there been any bleeding or discharge
5) Metastatic changes: has there been any weight loss, yellowish change in the color of your skin, poor appetite, night sweats
CARE SO FAR
What have you done so far for this condition
Have you visited any prayer house , pharmacy or hospital Have you taken any local concoction or were you given any medications
Have you done any investigations? Pelvic ultrasound , pap smear
OBSTETRICS HISTORY
How many pregnancies have you had so far
In what year did you give birth
Did you have any events during your pregnancy.
Did you have any fever or rash
How long did your carry the pregnancy, was it up to term
What was the mode of delivery.,
was it vaginal or cesarean section
If vaginal was it spontaneous or induced
How long did the labor last
Was there any complications like bleeding
How many days did you stay in the hospital
Is the child alive and well
GYNECOLOGY HISTORY
At what age did you see your first menstrual period (at what age did you stop having your periods)
How many days do you bleed for
Do you see your period every month
How you know the length of your cycle
Do you have menstrual cramps
How many pads do you usually use
Do you have painful sexual intercourse
Have you had any abortions or miscarriage in the past
Are you aware of contraceptives, do you use any.
Are you aware of pap smear, have you done one?
PAST MEDICAL HISTORY
Have you had similar conditions in the past
Have you have any history of chronic illnesses like hypertension, epilepsy asthma, diabetes, sickle cell disease have you had any surgery, blood transfusion or hospitalization in the past? if yes… why?
FAMILY HISTORY
Any history of similar conditions in your family ( heads)
SOCIAL HISTORY
Do you smoke, do you drink alcohol, do you have multiple sexual partners
DRUG HISTORY
Drug history
Are you on any long term medication? Are you on any current medications?
Do have any drug allergy
REVIEW OF SYSTEM
Ma. just to be sure I didn’t miss any symptoms, I would like you to say yes or no to the following questions
Cns: any headache, blurry vision, seizures
Endo: any neck swelling , excessive weight loss or weight gain
Resp: any snoring, noisy breathing, fast breathing
Cvs; cough, chest pain, palpitations
Dig: any abdominal pain, nausea or vomiting
Gus: increased urination, blood in urine, discharge from private part
Mss: joint pain, joint stiffness, difficulty walking
Thank your examiner
