History clerking, physical examination of Obstetrics patients. Etiquette: Always introduce yourself,tell the patient who you are and say why you have come to see them. Sensitive to intensely private data. Some women will wish another person (chaperon ) to be present if the doctor or students is male (even female), even just to take a history and this wish should be respected IDENTIFICATION DATA : Name: Ethnicity: Age: * <18y.o, *>35y.o Date of birth: Date of admission: Date of delivery/operation: delivery/operation: Date of discharge: Date of clerking:
R/N: Ward : nd marital status: SMS/2 union
Gravida/ para: (twins/abortion/molar (twins/abortion/molar pregnancy) Gravidity : no. of pregnancies of any gestation regardless of how they ended; , including present one Parity = Number of live births at any gestation and stillbirths delivered after stage of viability (24wks) (either by vaginal or operative routes) E.g.: 1) Lady on her 1st pregnancy – pregnancy – G1P0 G1P0 – G2P2 2) Woman had twins and pregnant now (24wks) – G2P2 3) A woman has had 4 miscarriages and is pregnant again with only one live baby; she is at 26 wks of gestation now – now – G6P1+4 G6P1+4 – G6P3+1 4) A lady in her 6th pregnancy, with history of 1 abortion and 1 molar pregnancy – G6P3+1 abortion,1 molar pregnancy.
VSMU OBGYN OBGYN workshop 2012
Last normal menstrual period(LNMP): Sure of date SOD Unsure of date USOD (calculated from REDD- ) REDD : ( if USOD, USOD, do early scan @ ~ 10weeks,if 10weeks,if >1 weeks discrepancy, discrepancy, REDD should be given .)
Period of amenorrhea (POA)/ gestation (POG) : POA by LMP; POG by U/S (if REDD is given earlier,use it to calculate POG) Expected date of delivery(EDD): delivery(EDD): ( if pregnant) by LMP or by scanning
EDD Naegele’s rule : Add 7 days to LMP, subtract 3 months from the month OR Add 7 days from LMP and add 9 months to the month. Criteria: 1. Regular MC 2. Not on OCP within 3 months 3. Not on breastfed prior to amenorrhea 4. Pregnancy not via ACT (IUI/IUD/IVF) (IUI/IUD/IVF) calculate POA from LMP: steps: 1.find LMP 2.minus date of clerking 3.change the months & day into week and then plus additional day & week. & follow this rules : or simply deduct the number of weeks from the EDD.
3 months = 13 weeks 2 months = 8 weeks 5 days 1 months =4 weeks 2 days. 1.
4 weeks + 2 days
2.
8 weeks + 5d
3.
13 weeks
4.
17 weeks + 2 d
5.
21 weeks +5d
6.
26 weeks
7.
30 weeks+ 2d
8.
34 weeks+ 5d
9.
39 weeks
VSMU OBGYN OBGYN workshop 2012
* Gregorian calendar says one month has 30-31 days (except Feb) or if in weeks, about 4.33 weeks. 1week = 7 days —1day ~ 0.14 week; 1mth = 31days= 4 weeks 3 days= 4 weeks + (3x 0.14 weeks )= 4.42 weeks 1 mth= 30 days = 4 weeks 2 days = 4 weeks + (2x 0.14)= 4.28 Average = (4.28+4.42) /2= 4.35 * maknanya we have about 0.42 week ( 3 days) missing missing each month. We have to correct this loss. Actually this 0.42 week loss akan akan menjadi 1 week week lepas tiga kali round, or three months months (0.42+0.28+0.42 = 1.12 week). (approximate 1 week) Sebab tu every 3 months, kita correctkan defect tu dengan add 1 week tadi. Meaning: 4 week + 4 week +4 week +1 week = 3 months
CHECK LIST FOR OBSTETRIC CASE 1. chief complaints 2. History of Present Illness 3. History of present pregnancy/antenatal pregnancy/antenatal history 4. Past Obstetric History 5. Gynaecological Gynaecological History 6. Contraception History 7. Past Surgical History 8. Past Medical History 9. Drug history 10.Family 10.Family History 11.Social 11.Social History 2.CHIEF COMPLAINTS(c/o): a) reason admitted b) test done eg. Diagnosed to have gestational diabetes at 30 weeks. *problem must be listed in priority if there are multiple problems and explained concisely and adequately Eg. Admitted upon her booking visit for high blood pressure of 150/93 mmHg compared to previous baseline blood pressures of approximately 120/80 mmHg.
Eg. Madam Ling is a 25 y.o Gravida 3 para 2 chinese,at 32 weeks POA who is admitted for painless PV bleeding for 1 day duration for further management. th Her LMP was on 15 September 2011.she has regular 28-30 days menstrual cycle. Therefore her nd EDD is on 22 of june 2012 by LMP.
VSMU OBGYN OBGYN workshop 2012
3.history of presenting illness 4.history of presenting pregnancy (HOPP)
Marital status : when,age,how many marriages This is her ___ pregnancy with POA ____ 1. Unexpected but wanted or ―unwanted‖? or planned? 2. Why suspect pregnancy? pregnancy? 3. When?where?who?how When?where?who?how to confirm pregnancy? Urine pregnancy test (UPT)? Ultrasound? Patient got married in 1992. According to the patient, this is a “long awaited”/planned pregnancy after being unable to conceive for 17 years. Her suspicion of a pregnancy was raised when she started having symptoms of pregnancy such as nausea and morning vomiting episodes. She had a urine pregnancy test at POA 17 weeks at Klinik Kesihatan Marang and was tested positive.
Early pregnancy(check antenatal book- pink book) Booking date - ___ ( @ POA) , @KKIA ___ Booking BP – Height – Weight — — Blood group & rhesus-Haemoglobin-Urine glucose-Urine protein-VDRL-HIV --(fundal height) —
Immunization (when? How many doses?) Antitetanus toxoid Hepatitis B rubella
Others : MOGT done? (indication : FHx,age > 35,excessive weight gain, previous macrosomia,GDM,fetal abnormalities) Subsequent antenatal check up 1. Usually monthly till 28weeks fortnightly till 36weeks weekly till EDD
VSMU OBGYN OBGYN workshop 2012
2. Ask : Date of visit: ….same as above…noted if any changes Weight gain ,BP,Hb,urine protein,urine glucose,uterine size, fetal movement (primigravidae (primigravidae 18-20 weeks multigravidae 16-18weeks increase in frequency & intensity?)oedema? intensity?)oedema? Thi s is he r se con d pr egn ancy an cy aft er 15 years years of no no preg pregna nancy ncy.. She She is curre currently ntly at 38 38 wee weeks ks and 6 days of gestation. This pregnancyis unexpected but wanted. She had a period of amenorrhea for four months but she did not expect for getting pregnant because of certain re aso ns, 1) sh e ha d be en hav in g i rr egu la r menstr menstrua uatio tion n afte afterr her her first first child child,, and and 2) she is obese and she only thought of having gained weight. Her suspicion of a pregnancy was raised when she started having symptoms of pregnancy such as nausea and morning vomiting episodes. She had a urine pregnancy test at POA 17 weeks at K linik Kesihatan and was tested positive. Booking was done on 6th July 10 at POA 17 weeks. She was told that her BP was normal (120/83mmHg), weighed 83 kg, height measured 150 cm, presence of edema, Hb normal (13.0gm/dL), blood group and Rhesus was B+, VDRL and HIV non-reactive, absence of glycosuria or albuminuria. 2 doses of anti tetanus toxoid were given, once in the end of September and October. Patient took an MOGT test upon her 1 5.0mmol/L.
st
booking and results were normal, 4.4mmol/L; 2
nd
hour
Patient had a weight gain of 6kg throughout the pregnancy, from 83kg-89kg. She claimed that her weight was never drastic in nature, ie. not more than 2kg per week.
5. PAST OBSTETRIC HISTORY (POH) Primigravida/ multigravida multigravida Name the complicated one,then uneventful one.
If more than 3 children, 1. Summarize all the uneventful cases How many boy and girl? Weight range? 2. Contraceptive method 3. Pregnancy spacing (>2 yrs,consider ―normal‖; >5 yrs,why??voluntary?) yrs,why??voluntary?)
VSMU OBGYN OBGYN workshop 2012
LIST THE PREVIOUS PREGNANCIES 1. Year of deliveries 2. The health institution for the delivery etc. 3. TYPE OF DELIVERIES ‐ SVD, LSCS (elective?emergency?indication?c (elective?emergency?indication?counselling ounselling VBAC?? 4. POA at delivery 5. antepartum : Any medical problems? 6. intrapartum : complication 7. postpartum : complication (fever?prolong stay in ward?wound breakdown?PPH?blood breakdown?PPH?blood transfusion?) 8. Babies ‐ weight, sex, abN, neonatal cx, alive/dead 9. breastfed – till when; bottlefed- why? 10.If 10. If miscarriage ‐ how many times?their POA, cause ?, ERPOC? 11.If 11. If previous extopic pregnancy – site of ectopic?how was it managed?
Eg. She had delivered 5 children between 1992 till 1997 which were all uneventful spontaneous vaginal delivery with babies weight ranging between 2.8 to 3.5 kg. All the children were normal, alive and well.
Eg. She delivered her 1 st child back in year 1993 through SVD. The baby girl was a termed child, weighing at 3.4kg. Her blood pressures and diabetes status were normal throughout, ie. no history of PIH or GDM. Patient received an episiotomy and the scar healed without complications. Apart from that, the rest of the antenatal, intrapartum and post-partum history were all uneventful.
Eg. If the POH is complicated, complicated, give the main findings findings first.
CLERKING A COMPLICATED PAST OBSTETRIC HISTORY Past h/o Miscarriage Miscarriage ‐ Which trimester was it ? ‐ Was it a confirmed pregnancy ? UPT/Ultrasound? ‐ Was any ERPOC performed ? ‐ Was there any complication such as infection / foul smelling PV discharge, delayed period ? VSMU OBGYN OBGYN workshop 2012
Eg PRESENTING A COMPLICATED PAST OBSTERIC HISTORY – h/o Miscarriage She had delivered 5 children between 1992 till 1997 with a history of one miscarriage in the third pregnancy. The miscarriage at 9 weeks POA was a confirmed confirmed pregnancy diagnosed by ultrasound. An ERPOC was performed and there was no complication following the procedure. The rest of the pregnancies were delivered by spontaneous vaginal delivery The babies weights ranged between 2.8 to 3.5 kg. All the children were normal, alive and well.
6. Past GYNAE / MENSTRUAL HISTORY Menses regular/irregular regular/irregular and what is the range ?
Formula = 12 (
28− 28 −30 30 5 −7
)
Pattern of menstruation : flow normal / minimal / heavy ? ( ask : clots ,flooding,wearing ,flooding,wearing double protection?nocturnal soiling) duration of flow ? associated with dysmenorrhoea dysmenorrhoea (menstrual pain?intermenstrual bleeding?) Menarche? Sexual Intercourse ‐ Any dyspareunia ? Superficial or deep ? postcoital bleed? Any other gynaecology problems such as PV discharge ? Any pap smear done ?how many times?result?the date of last pap smear? Previous history of subfertility? How long?frequency of intercourse adequate?(normally,2 adequate?(normally,2 or 3 times a week or timed in relation to ovulation.) Further consultation?result? consultation?result?
7. CONTRACEPTION HISTORY Clerking the Contraception History 1. How many children does the couple wants ? 2. Is the family complete ? 3. What form of contraception are they practising or intend to use ? What have they used before ? 4. Do you think their compliance can be assured ? VSMU OBGYN OBGYN workshop 2012
PAST MEDICAL / SURGICAL History Past history of pre existing diseases : • Hypertension • Thyroidism • Blood diseases : anemia • diabetes mellitus, • asthma, COPD, • heart disease, • epilepsy, • renal dss, • venous thromboembolic dss, • CT dss: SLE TB,hepatitis,rubella,HIV • Infection : TB,hepatitis,rubella,HIV • myasthenia gravis/myotonic dystrophy etc Any relevant past history of hospitalization hospitalization (including past operation done) e.g appendectomy, hernial repair, Bowel operation etc Mention the year of diagnosis Mention the status of condition Eg: Hypertension ‐10 years on regular treatment Diabetes type II – 6 years on dietary control
Have you ever suffered with your ―nerves‖? Had u any problem with depression or the ―blues‖ after the birth? possible depression. During the past month, have you often been bothered by feeling down, depressed or hopeless? During the past month, have you often been bothered by having little interest or pleasure in doing things?
8. DRUG HISTORY Prescribed drugs Name, Dose, Duration or what is it for, what colour, how many times a day, how long. On prescribe drugs (over the counter) Herbal or complementary therapy History of allergies to drugs Name of the drugs, what actually happens when patient took the drugs VSMU OBGYN OBGYN workshop 2012
Rashes, swelling of face & difficulty breathing are important allergic reactions Nausea, vomiting or diarrhea are not necessarily allergic reactions Allergy to certain food?
9. FAMILY HISTORY Relevant family history of sibling and parents e.g Diabetic, hypertension, heart disease, thromboembolic thromboembolic diseases,pre-eclampsia,psy diseases,pre-eclampsia,psychotic chotic psychiatric disorder,twins, breast cancer, Ovarian cancer etc congenital abnormality Hereditary
10.PERSONAL 10.PERSONAL & SOCIAL HISTORY ‐ education ‐ patient / husband’s husband’s age,occupation and income -visited by husband?how many times/day? ‐ smoking, alcohol or drug abuse ‐ who is taking care of children ‐ recent travels ‐ domestic condition ‐ Sexual activity
VSMU OBGYN OBGYN workshop 2012
