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Obstetrics clinical interview


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Obstetrics clinical interview. For exams & clinicals
Presenting your case
Essential points in house officer's/ residents' history taking.

Published in: Health & Medicine
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Obstetrics clinical interview

  1. 1. Yapa Wijeratne Obstetrics clinical interview 1. Introduction - Name - Age - Address - Occupation - Marital status - Married for how long - Number of children - Reason for admission Details of present pregnancy - Pregnancy – accidental/planned - Parity, gravidity, children G P C - LRMP - EDD - EPD - POA 2. Presenting complaint Ex. Lower abdominal pain for 3 days In obstetrics, other than requested admissions commonly there are 6 presenting complains. I. Abdominal pain II. Back pain III. Fetal movements (FM)-reduced IV. PV bleeding V. Dribbling VI. PET symptoms- headache/ epig pain/ visual blurring 3. Subsidiary complaints Complaints other than the presenting complaint with duration 4. History of presenting complaint - Include the nature and details of the presenting complaint in chronological order Ex. 1. Abdominal pain - Site – lower abdomen/suprapubic/lumbar/general ized/local - Type – constricting, throbbing, lancinating, colicky - Severity – mild, moderate, severe - Frequency – duration of pain and the duration of pain free interval - Radiation of pain - Relieving or aggravating factors Labor pains – colicky lower abdominal pain radiating to thigh, gradually increasing in frequency and severity 2. Bleeding PV - Duration - Fresh/ altered blood - No of pads used per day - Clots/ floods - Signs of hypovolaemia - Painless bleeding – placenta previa - Painful bleeding – placenta abruption - Blood and mucus – show 5. History of subsidiary complaints - describe the subsidiary complaint in detail 6. Present obstetrics history 1. When the pregnancy was first diagnosed? How – gravindex test urinary hCG,USS 2. Booking visit (1st clinic visit) Place – local hospital, MOH, Base Hospital, general hospital 3. Who conduct the clinic? – MOH,DDHS,VOG,PHM,PHNS 4. What was done there? History Examination
  2. 2. Yapa Wijeratne Investigation – - blood group - VDRL - Hb% - RBS - Blood grouping - Urine Sugar - Urine Albumin - UFR - USS 5. Treatments given - Tetanus toxoid - Folic acid - Fe tablets - Calcium tablets - Worm treatments 6. What advices given? 7. What happened during pregnancy? T1- vomiting Bleeding UTI Drug treatments Exposure to radiation Booking scan Dating Uss – late 1st trimester or early 2nd 12/52 , before 20 weeks T2- vomiting Bleeding Quickening – the date of feeling fetal movement by the mother for 1st time. For primis it is around 20wks and 18 for multiparous Tetanus Anomaly scan and other investigations T3- fetal movements, bleeding, dribbling/show, abdominal pain, backache 8. Investigations – DM, PIH, Blood group, Hb% 7. Past obstetrics history 1. No of child births - Type of delivery - If LCSC – indication - When, at what POA, sex of babies, BW - Alive or not - Place of delivery - Rhogum given or not if mother is Rh- ve - Associated DM, PIH or any other diseases 2. Neonatal deaths – congenital abnormalities - post mortem findings 3. Still births – POA Fresh/ macerated Mode of delivery 8. Menstrual history - Age of menarche - Regular or not - Duration of bleeding - Frequency - Amount of bleeding - Dysmenorrhoea - Intermenstrual bleeding 9. Past clinical History - Gynaecological history Abortions – POA Spontaneous/induced ERPC/D&E done or not No of abortions  Ectopics – POA
  3. 3. Yapa Wijeratne Ruptured/ Unruptured Management  History of infertility – if present For how long Treatments given Follow up  Any previous gynaecological conditions ( fibroids endometriosis) or surgeries (myomectomy)  STD – PID, Chlamydia, gonorrhea, hepB, HIV - Past medical history  Any major illnesses – DM, BA, HT, HD - Past surgical history  Any surgery in the past  Under general/ local anaesthesia  Post surgical complications 10. Contraceptive history - Methods used – OCP,DMPA injection, Condoms o Duration of usage o Date of stop o Any side effects – wt gain. menorrhagia 11. Drug history  Food or drug allergy  Antihypertensive, diabetic, antiepileptic and thyroid medications 12. Family history  HT, DM, IHD  Congenital abnormalities  History of twins - Still birth, IUD, abortions - Pregnancy complications - Ovarian or breast ca 13. Social history  Occupation of the patient/ husband – income  # of children ages, what are they doing?  Distance from the house - Husband – smoking, alcohol - Current social problems - Water for drinking – from where - For washing from where? - Toilet – water sealed - Hygiene – use of slippers 14. Dietary History- Unless for anemia in pregnancy, no much role in history as anyway during pregnancy, every pregnant lady concerns about good diet. - Food habits - Food allergy - If on diet control on advice - From where did you get the advice? - Type of diet - Frequency - For how long Before the clinical interview introduce yourself as a medical student and get the permission for the interview and examination. Examination Not everything is relevant. Only highlight the important findings. General - Wt - Ht - BMI - Mucous membranes/ pallor - General appearance – looks ill or well - Skin - rashes, bleeding patches
  4. 4. Yapa Wijeratne - Eyes – pallor, icterus, polycythemia - Mouth – central cyanosis in tongue/lips  Dental caries, pallor - Thyroid - Hands  Peripheral cyanosis  Jaundice  Nails – clubbing,discoloration, koilonikia, palmar erythema (physiologic in pregnancy) - Lower limbs  Ankle edema ( unilateral/ bilateral)  Varicose veins ABDOMEN - Exposure – cover around the bed with curtains to maintain the privacy, with the consent, expose from xiphisternum down to the suprapubic region - Inspection  Signs of normal pregnancy – linea nigra, striae gravidarum  Assess the size and the shape of the abdomen  distension of the abdomen - symmetrical/ asymmetrical  any visible fetal movements  umbilicus – inverted/ everted, discharges  scars- LCSC on suprapubic region (pfenestitial fascia)  other surgical and non surgical scars  striae  skin lesions - palpation  ask for any tender area before palpation  keep eye contact with the patient every few seconds while you are examining  prevent hurting by gentle palpation  eliciting scar tenderness in past section- ask the patient whether she gets pain when pressing the scar toward the legs with two fingers (if yes- true scar tenderness as LSCS scar is actually at pelvis level) & press towards the abdomen (if says yes- not true scar tenderness. ) Measuring for the fundal height  Palpate the upper margin of the fundus by placing the ulnar border of the left hand gently  Palpate the pubic symphysis  Apply measuring tape  Stretch tape from the fundus to symphysis pubis  Then measure the fundal ht in cms. ( to prevent the bias measure in inches and turn over to read in cms) Determination of presentation and lie  Palpate the lower pole with both hands facing down on the abdomen. Palpate the upper pole gently with both hands facing upwards over the abdomen  Ex. If head is in lower pole and the breech is
  5. 5. Yapa Wijeratne in the upper pole – cephalic presentation  If breech is in the lower pole with head in upper pole – breech  Both are longitudinal lie  Palpate with the hand on either side by facing hands upwards  Identify spine in continuous with head on one side and the moving limbs as separate bony particles on the other side.  Ex. In cephalic presentation – if spine is left it is left occipito anterior or L.O. posterior  In breech presentation if the spine is in the left it is left sacro anterior or L.S. posterior  If you palpate more than one head and multiple body parts It is a multiple pregnancy.  Palpate for the kidneys. – during pregnancy kidneys are displaced upwards  Palpate for liver and spleen - Auscultation  FHS – listen to the FHS with pinard stethoscope ( locate relative to the anterior shoulder )  Calculate heart rate Breast - Nipple – inverted / everted, abnormal discharge- for breast feeding suitability - Any lumps - Skin lesions – ulcers, pigmentation Detailed CVS/ RS/ CNS if relevant only. CVS  Pulse  BP  JVP  Precordium Sample History for busy wards In busy wards it is not practically possible to ask each & everything. Same way not everything is relevant for management. So this is basic outline for important component of house officer’s history. P1C0 Blood group LRMP EDD USS dates corrected at POA 12 POA Placenta- fundal P/C OGTT-Normal Abdo pain + Back pain+ FM + PV bleeding 0 Dribbling 0 PET symptoms 0 T1 T2 Not significant. PIH0 GDM0 T3 PMHX PSHX Not significant Allergy Social-H/w O/E Afebrile Pallor Pulse 72 bpm BP 110/70 mmHg
  6. 6. Yapa Wijeratne DR+ VB+ Abdo- SFH 38cm CP HNE VE OS- 1cm Cervix- 30% effaced Station (-1) Speculum (if dribbling) True dribbling + Liquor- clear Presenting abdominal examination findings. This can be done while doing examination as a running comment or after the completion of examination. 1. Inspection “Abdomen is distended with signs of pregnancy such as linear nigra/ striae gravidarum etc. No surgical scars. There are visible fetal movements (no need to comment if can’t see). Hernial orifices intact (asking pt to cough- optional step) 2. Fundal height “Her SFH is 38 cm which is compatible with her POA” 3. Palpation of lower pole- presentation “There is a hard round ballotable mass in the lower pole which is 4/5th palpable. Therefore this fetus is cephalic presentation & head is not engaged.” 4. Palpation of upper pole- lie & number of fetuses “I can feel one firm round mass in the upper pole which is breech & therefore this is longitudinal lie & single fetus” 5. Palpation of the sides- for the back & the limbs/ position “I can feel regular board like mass connecting head & breech (more towards the midline) on the left- spine & irregular boggy masses on right- limbs. Therefore fetus is in left occipitoanterior position.” 6. Estimated fetal weight /EFW “EFW is about 3 kg” 7. Liquor amount “Liquor is adequate” 8. Auscultation for FHS “FHS is 140/min which is normal”