Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

01 history and examination dr isameldin

628 views

Published on

history and examination in obstetrics and gynaecology fo MBBS students

Published in: Health & Medicine
  • Be the first to comment

01 history and examination dr isameldin

  1. 1. Dr. Isameldin Elamin MD DOWH MBBS Assistant professor Obstetrics & Gynaecology department
  2. 2.  By the end of this lecture the student should be able to:  Take a detailed obstetric and gynaecological history.  Describe how to conduct obstetrical and gynaecological examination.  Describe how to conduct digital and speculum pelvic examination. 3/4/2016dr isameldin 2
  3. 3. History in Obstetrics and gynaecology:  Sensitive topics.  Sensitive area.  Sensitive information. History taking needs to:  Build a good rapport with the woman.  Closed room with adequate facilities and privacy. 3/4/2016dr isameldin 3
  4. 4.  At a booking visit, the history. must be thorough and meticulously recorded.  Ask yourself what you need to achieve.  Ask why the patient has attended. (May be routine visit).  Make sure that the patient is comfortable. 3/4/2016dr isameldin 4
  5. 5.  Polite when talking to the patient.  Good listener.  Non judgmental.  Appearance is suitable before you enter the room.  Introduce yourself.  Tell why you have come to see them. 3/4/2016dr isameldin 5
  6. 6.  Name.  Age.  Occupation.  Marital status.  Residence.  Education.  Booking status. 3/4/2016dr isameldin 6
  7. 7.  Duration of marriage.  Name of the husband.  Age of husband.  Consanguinity.  Make a note of ethnic background. 3/4/2016dr isameldin 7
  8. 8.  Presenting complaint.  Details of the presenting problem.  Reason for attendance if no complaints.  Write in the patient's own words. 3/4/2016dr isameldin 8
  9. 9.  Arrange in order of occurrence.  eg:  1-vomiting / today.  2-abdominal pain / 2days.  3-fatigue / 3days. 3/4/2016dr isameldin 9
  10. 10.  Vaginal bleeding.  Gush of fluid per vaginum.  Abdominal pain.  Persistent headache.  Blurring of vision.  Edema of hands or face.  Persistent vomiting.  Diminished or absent fetal movements. 3/4/2016dr isameldin 10
  11. 11.  Gestational age:  last menstrual period (LMP) or estimated date of delivery (EDD)  Pregnancy duration is 280 days (40 weeks).  Add 9 month and 7days (14 Arabic) to calculate EDD. (Naegele`s rule need 28 day cycle). 3/4/2016dr isameldin 11
  12. 12.  Dates can be calculated from ultrasound before 20 weeks by:  The crown–rump length is used up until 13 weeks 6 days.  Head circumference from 14 to 20 weeks.  After 20 weeks, variability of growth makes it unsuitable. 3/4/2016dr isameldin 12
  13. 13.  Accurate EDD is important because:  Serum screening for down’s syndrome.  Induction of labour for post-dates pregnancy. 3/4/2016dr isameldin 13
  14. 14.  What action has been taken? Is there a plan for the rest of the pregnancy?  What are the patient’s main concerns?  Have there been any other problems in this pregnancy? 3/4/2016dr isameldin 14
  15. 15.  First trimester  Morning sickness.  Bleeding, pain, discharge.  Drugs , radiation, febrile illnesses.  Second trimester:  Bleeding, pain, discharge, UTI.  Edema.  Quickening. 3/4/2016dr isameldin 15
  16. 16.  Bleeding, pain, discharge.  Fetal movement.  Symptoms of labour.  Febrile illnesses. 3/4/2016dr isameldin 16
  17. 17.  Vaccination.  Ultrasound  What scans have been performed?  Why?  Were any problems identified? 3/4/2016dr isameldin 17
  18. 18.  Gravida – G:  is the total number of pregnancies regardless of how they ended.  Parity – P:  is the number of live births at any gestation or stillbirths after 24 weeks.  In terms of parity, twins count as two.  (Ten teacher s,19th edition). 3/4/2016dr isameldin 18
  19. 19.  Williams reference:  Parity is the number of pregnancy reaching viability, so In terms of parity, twins count as one.  G2P1A0L2.(twins in first pregnancy)  So we consider this in our college. 3/4/2016dr isameldin 19
  20. 20.  Gravida 1, parity 0 A0  Gravida 2, parity 2A0 (twins).  Gravida 8, parity 1A6 (abortion 6).  G8 P1 A6L1 GA 25 weeks. 3/4/2016dr isameldin 20
  21. 21.  Outcome of each pregnancy.  When.  G.A.  Weight.  Sex.  Alive or dead now.  Recurrent miscarriage . 3/4/2016dr isameldin 21
  22. 22.  Fetal growth restriction (FGR).  Preterm delivery.  Pre-eclampsia .  Abruption.  Congenital abnormality .  Macrosomic baby.  Unexplained stillbirth. 3/4/2016dr isameldin 22
  23. 23.  Method of delivery of previous pregnancies and complications:  Caesarean section.  difficult vaginal delivery.  postpartum haemorrhage.  significant perineal trauma.  Breast feeding. 3/4/2016dr isameldin 23
  24. 24.  Periods: menarche, regularity.  Contraceptive history.  Previous infections and their treatment.  When was the last cervical smear? Was it normal? 3/4/2016dr isameldin 24
  25. 25.  Previous gynaecological surgery.  Previous ectopic pregnancy.  Recurrent miscarriage.  Previous history of sub-fertility and IVF. 3/4/2016dr isameldin 25
  26. 26.  Relevant medical problems:  Diabetes mellitus.  Hypertension.  Bronchial asthma.  Renal disease.  Epilepsy. 3/4/2016dr isameldin 26
  27. 27.  Venous thromboembolic disease.  Sickle cell anaemia.  Human immunodeficiency virus (HIV) infection.  Connective tissue diseases.  Myasthenia gravis/ myotonic dystrophy. 3/4/2016dr isameldin 27
  28. 28.  Any previous operations.  Psychiatric history:  Postpartum blues or depression.  Depression unrelated to pregnancy.  Major psychiatric illness.  Domestic violence. 3/4/2016dr isameldin 28
  29. 29.  Enquiry of other systems.(Systemic review).  CNS  RS  CVS  GIS  MUSCLOSKELETALS 3/4/2016dr isameldin 29
  30. 30.  Diabetes, hypertension, genetic problems, psychiatric problems, etc.  Thromboembolic disease.  Pre-eclampsia .  Congenital abnormality .  Haemoglobinopathies.  Tuberculosis. 3/4/2016dr isameldin 30
  31. 31. Multiple pregnancy. Congenital anomalies. Cancers (e.g.. Breast).  Allergies. 3/4/2016dr isameldin 31
  32. 32.  Smoking/alcohol/drugs/ Khat.  Housing.  Occupation, partner’s occupation.  Who is available to help at home?  Are there any housing problems? 3/4/2016dr isameldin 32
  33. 33.  All medication including over-the-counter medication.  Folate supplementation.  Any regular medications.  Allergies:  To what?  What problems do they cause? 3/4/2016dr isameldin 33
  34. 34.  The history should be summarized in one to two sentences  Example:  MRS X 34 years old teacher G5P3A1 GA 37 weeks with previous C/S known hypertensive admitted for control of BP.  Age.  G_ p_ +_  GA  Any chronic condition.  Cause of admission. 3/4/2016dr isameldin 34
  35. 35. 3/4/2016dr isameldin 35
  36. 36.  Principles of infection reduction.  Remove any wrist watches or rings with stones.  Bare arms from the elbow down.  Wash hands or use gel before and after any patient contact. 3/4/2016dr isameldin 36
  37. 37.  Maternal weight and height:  Calculate body mass index BMI. [Weight (kg)/height (m2)].  Risk for BMI <20 >30. 3/4/2016dr isameldin 37
  38. 38.  Hypertension diagnosed >140/90 mmHg on two separate occasions at least 4 hours apart),  Measured woman seated or semi-recumbent.  Use an appropriately sized cuff.  Use Korotkoff v, (disappearance of sounds). 3/4/2016dr isameldin 38
  39. 39.  Women presenting for a routine visit there is little benefit in a full formal physical examination.  Examine:  Inspect when enter for gait height etc.  Eye, tongue, Teeth palm etc.  Neck, Thyroid often palpable. 3/4/2016dr isameldin 39
  40. 40.  Cardiovascular examination:  In asymptomatic women with no cardiac history is unnecessary.  Flow murmurs can be heard in approximately 80 per cent of women at the end of the first trimester.  Breast examination:  Formal breast examination is not necessary. 3/4/2016dr isameldin 40
  41. 41.  Inspection  Shape of the uterus  Asymmetry.  Fetal movements.  Scars.  Striae gravidarum.  Linea Nigra. 3/4/2016dr isameldin 41
  42. 42.  Palpation: (deep and superficial)  Symphysis–fundal height measurement.  Measure SFH and plot on an SFH chart.  In late third trimester SFH the fundal height is 2 cm less than the number of weeks. 3/4/2016dr isameldin 42
  43. 43. 3/4/2016dr isameldin 43 Symphysis–fundal height measurement.
  44. 44.  Fetal lie, presentation and engagement.  Palpate to count the number of fetal poles. For multiple pregnancy.  Lie: longitudinal, oblique or transverse 3/4/2016dr isameldin 44
  45. 45.  The presentation:  is the part of the fetus in the lower pole of the uterus overlying the pelvic brim (cephalic, breech).  The lie of the fetus:  is the relation of the long axis of the fetus to the uterus (could be longitudinal, oblique or transverse. Only longitudinal lie is normal) 3/4/2016dr isameldin 45
  46. 46.  The attitude:  is the posture of the fetus (flexion, deflexion, extension)  Position:  the position of the fetal presenting part in the maternal pelvis in relation to the denominator. 3/4/2016dr isameldin 46
  47. 47.  Denominator are:  Occiput in vertex presentation  Sacrum in breech presentation  Mentum in face presentation  (e.g. Occipitoanterior, sacroposterior). 3/4/2016dr isameldin 47
  48. 48. 3/4/2016dr isameldin 48
  49. 49.  Station:  is the relation of the presenting part to the ischial spine. If the presenting part is at the level of ischial spine, station =0  Engagement:  the descent of the biparietal diameter through pelvic brim. If the head is at the level of ischial spine the head must be engaged. 3/4/2016dr isameldin 49
  50. 50. 3/4/2016dr isameldin 50
  51. 51.  Fundal grip:  Palpate the fundus (to determine if it contains breech or head)  By gentle pressure If breech:  soft consistency, indefinite, outline  If head, it is hard, smooth, well defined, palatable. 3/4/2016dr isameldin 51
  52. 52.  Mobility to differentiate between head and breech:  move your fingertips over the fetal mass to determine.  If moves freely between fingertips it is the head  If can’t move independent from the body it is the the breech. 3/4/2016dr isameldin 52
  53. 53. 3/4/2016dr isameldin 53
  54. 54. Lateral Palpation (B): (determine the position of the fetal back and small parts) 3/4/2016dr isameldin 54
  55. 55. Pelvic palpation (C): 2 maneuvers Pawlik's manoeuvre, or 1st pelvic grip 3/4/2016dr isameldin 55
  56. 56. 2nd pelvic grip for engagement 3/4/2016dr isameldin 56
  57. 57.  Using a two-hand, and watching the woman’s face, gently feel for the presenting part.  The head is generally much firmer than the bottom. 3/4/2016dr isameldin 57
  58. 58.  Assess for engagement.  5/5th palpable means head not engaged.  1/5th or 2/5th palpable means head engaged.  The fetal position:  Occipito-posterior, lateral or anterior.  Position is Important when labour begins. 3/4/2016dr isameldin 58
  59. 59.  Fetal heart beat by hand-held device or Pinard stethoscope.  Best position is over the fetal shoulder. 3/4/2016dr isameldin 59
  60. 60.  Digital or speculum.  Consent.  Female chaperone should be present.  It is necessary in:  Excessive or offensive discharge.  Vaginal bleeding.  To perform a cervical smear.  To confirm rupture of membranes. 3/4/2016dr isameldin 60
  61. 61.  To assess the cervix.  It provide information about:  Dilation of cervix.  Position.  Station of presenting part.  Consistency of cervix..  Length of cervix. (Effacement). 3/4/2016dr isameldin 61
  62. 62.  Introduce two fingers into the vagina.  Bishop score can be calculated. 3/4/2016dr isameldin 62
  63. 63. 3/4/2016dr isameldin 63
  64. 64.  Oedema of the extremities.  Facial oedema.  Assess reflexes in pre-eclampsia.  Fundoscopy in hypertension and in severe pre-eclampsia. 3/4/2016dr isameldin 64
  65. 65. Gynaecological History And Examination 3/4/2016dr isameldin 65
  66. 66.  Same like in obstetrics History. 3/4/2016dr isameldin 66
  67. 67.  (Patient’s own words).  History of presenting complaint e.g:  Menstrual problems.  Pain.  Subfertility.  Urinary incontinence. 3/4/2016dr isameldin 67
  68. 68.  Age of menarche.  Duration of period and length of cycle. (5/28).  First day of the last period LMP.  Pattern of bleeding: regular or irregular.  Amount of blood loss.  Any inter-menstrual or post-coital bleeding.  Any pain relating to the period.  Any medication taken. 3/4/2016dr isameldin 68
  69. 69.  Site, nature, severity.  Aggravating or relieving factors.  Relationship to menstrual cycle and intercourse,  Radiation.  Association with bowel or bladder functions. 3/4/2016dr isameldin 69
  70. 70.  Amount, colour, odour, presence of blood  Relationship to the menstrual cycle  History of sexually transmitted diseases (STDS).  Vaginal dryness (post-menopausal). 3/4/2016dr isameldin 70
  71. 71.  The type of contraception.  Sexual history:  Availability of husband.  Frequency of intercourse.  Difficulties or pain during intercourse.  Post coital bleeding. 3/4/2016dr isameldin 71
  72. 72.  Last smear.  Previous abnormalities  Menopause (where relevant).  Date of last period.  Post-menopausal bleeding.  Menopausal symptoms. 3/4/2016dr isameldin 72
  73. 73.  Gynaecological history:  Previous gynaecological history.  Previous gynaecological treatments or surgery.  Previous obstetric history:  Number of children.  Number of miscarriages.  All details of pregnancy out comes. 3/4/2016dr isameldin 73
  74. 74.  Previous medical history.  Family history.  Enquiry of other systems.(Systemic review).  Social history. 3/4/2016dr isameldin 74
  75. 75.  Patient’s consent should be taken.  Chaperone should be present,  Watch patient walking into the examination room. 3/4/2016dr isameldin 75
  76. 76.  Examining the hands and mucous membranes The supraclavicular area for Virchow's node (Troissier’s sign).  The thyroid gland.  The chest and breasts.  A general neurological assessment. 3/4/2016dr isameldin 76
  77. 77.  Empty the bladder.  Patient should be comfortable.  Lying semi-recumbent.  Cover patient with a sheet.  Comprises:  Inspection.  Palpation.  Percussion.  Auscultation. 3/4/2016dr isameldin 77
  78. 78.  Inspect :  The contour of the abdomen.  Distension or mass.  Surgical scars.  Dilated veins.  Striae gravidarum.  Laparoscopy scars .  pfannestiel scars.  Hernias. 3/4/2016dr isameldin 78
  79. 79.  Superficial and deep.  Area of pain should be examined at the end of palpation.(soft)  Palpate 4 quadrant of abdomen.  Palpate for masses.(deep) the liver, spleen and kidneys.  Mass can not palpate below it, it is pelvic in origin.  Look for signs of peritoneum, i.e. Guarding and rebound tenderness. Examined for inguinal hernias and lymph nodes. 3/4/2016dr isameldin 79
  80. 80.  Percussion is particularly useful if free fluid is suspected.  Look for :  Dullness in the flanks.  Shifting dullness’.  A fluid thrill.  Aware full bladder is dull due to urinary retention. 3/4/2016dr isameldin 80
  81. 81.  Auscultate for bowel sounds in:  Bowel obstruction.  Postoperative patient with ileus. 3/4/2016dr isameldin 81
  82. 82.  Obtain verbal consent.  Female chaperone should be present.  Empty the bladder.  Inspection.  Good light  Correct position inspect the external genitalia and surrounding skin.  Look for:  Prolapse  Sign of stress incontinence. 3/4/2016dr isameldin 82
  83. 83.  Using a bi-valve or Cusco's speculum.  Has a retaining screw.  Used for smear or swab.  A Sim’s speculum.  Used for prolapse.  Warm the speculum.  Use water as lubricant for smear. 3/4/2016dr isameldin 83
  84. 84. 3/4/2016dr isameldin 84
  85. 85. 3/4/2016dr isameldin 85
  86. 86.  Done to assess the pelvic organs.  Part labia with left hand.  Insert one or two fingers of the right hand into the vagina.  Palpated cervix.  Place the left hand on the abdomen.  Palpate the fundus of the uterus. 3/4/2016dr isameldin 86
  87. 87.  Place the tips of the fingers in the lateral fornix.  Palpate for adenexa (tubes and ovaries).  Pushing down with the fingers of the abdominal hand.  Look for:  Swelling or tenderness.  Palpate the posterior fornix. (Endometriosis). 3/4/2016dr isameldin 87
  88. 88. 3/4/2016dr isameldin 88
  89. 89.  Can be used in:  children.  Adults who have never had sex.  Less sensitive than a vaginal.  Uncomfortable.  Can detect a pelvic mass.  Recto vaginal examination may be useful. 3/4/2016dr isameldin 89
  90. 90.  Pass this information to others in a clear and concise format.  Summarize positive findings.  Consider situation.  Busy ward round.  Examination.  Be aware of sensitive information. 3/4/2016dr isameldin 90
  91. 91.  Gynaecology by ten teachers 19 editions.  Obstetrics by ten teachers 19 editions.  Oxford hand book of obstetrics and gynaecology  http://www.uptodate.com.  Appendix:  1-history template obstetric page 14.  2-history template of gynaecology page2. 3/4/2016dr isameldin 91

×