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Hx: Obstetric History

1. Introduction
1. consent 2. name, age, occupation + weeks?

2. Presenting Complaint
symptoms + 1. fetal movements 2. ? blood pressure 3. ? bleeding concerns (delivery, health of baby)

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3. Pregnancy History
Planned? Dates 1. LMP 2. cycle regularity 3. previous contraception (?COC)  EDD (9m + 7d)  USS confirmed dates? Antenatal Care = booking bloods, US scans, blood tests, diagnostic tests Complications = hypertension, proteinuria, bleeding = ?admissions

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4. Previous Obstetric History
“Is this your first pregnancy? How many times have you been pregnant before?” “Did you deliver the pregnancy? How many weeks deliver/miscarry/terminate?” 1. Year 2. Gestation 3. Delivery (incl. reason) 4. Weight 5. Complications/Outcome

5. Other History
Gynae History Medical History Drug History Family History Social History – last cervical smear & result, urinary symptoms – HypT, DM, DVT/PE  SC – incl. supplements, diet – PET, DM, DVT/PE + multiples + hereditary disorders – smoking, alcohol, illicit drugs – partner + accommodation, finances, social support

6. Finish
“anything else you want to tell me that I haven’t asked about?” “anything worrying you?”

Abdominal Pain = socrates + bleeding, systemic signs, contractions (ectopic pregnancy, miscarriage, preterm labour, placental abruption) (UTI, appendicitis etc.) Vaginal Bleeding = duration, amount, type + abdo pain, shock (miscarriage, hydatiform mole, placenta praevia, placental abruption) (local cervical/vaginal causes)

palmar erythema) (anaemia) (spider naevi. 5. 6.polyhydarminos/oligohydraminos 3. transverse cephalic/breech if longitudinal (head small & hard) ballotable presenting part? fifths of head palpable above pelvic brim + Fetal Movements + Liqour Volume . SFH 2. areolar pigmentation. 3. 2. Inspection 1. Palpation 1. Auscultation Fetal movments? SonicAid Doppler / Pinard stethoscope (placed at position of fetal thorax) Finish Recover patient & thank . pigmentation & freckles) (flow murmur) (fullness. 7. Montgomery’s tubercles. 4. 4. peripheral oedema) 1. 2. nipples) (varicose veins. Lie 3.ease in palpating fetal parts. striae gravidarum) (transverse suprapubicPfannensteil. laparoscopic) 2. long axis of uterus longitudinal. oblique. Presentation 4.Ex: Obstetric Examination Introduction Chaperone !! Consent Expose abdomen (above fundus to pubic hairline) Position comfortably General Examination 1. distension pigmentation scars fetal movements (linea nigra. Engagement – – – – – – – symphyseal-fundal height SFH (2cm) approximates to dates (weeks) direction fetal spine with respect o. SFH size . BMI Hands Eyes Skin Heart Breasts Legs (radial pulse. 3. chloasma gravidarum.

protein PET = ++ protein DM = + glucose.Hg) check appropriate cuff size (bladder 80% circumference) cuff on arm (brachial pulse. arm extended. level of the heart) inflate while palpating brachial pulse deflate while auscultating over brachial pulse record readings (b) Urine Dipstix gloves confirm fresh. bilirubiniruia. mid-stream sample inspect sample (cloudy. haematuria) immerse dispsitck wait 10s hold horizontally comparing to bottle UTI = + nitrites. blood. ketones . leukocytes.(a) Blood Pressure Measurement inform possible discomfort & ask if resting last 5 mins check sphygmomanometer (set to 0 mm.

social support 5. 4. heavy & frequent periods. DM. illicit drugs – accommodation. exercise. 2. dysmenorrhoea. Gestation 3. Year 2. Outcome – DVT/PE. consent 2. emotional upset. Other History Medical History Drug History Family History Social History 6. menarche age. dyspareunia. prolapse. previous STI Urinary – incontinence. Finish “anything else you want to tell me that I haven’t asked about?” “anything worrying you?” Menorrhagia Menopause Amenorrhoea PCOS Endometriosis = duration. amount. Presenting Complaint 3. acne. name. weight loss. 3. Previous Obstetric History “Have you ever been pregnant before?” “Did you deliver the pregnancy? How many weeks deliver/miscarry/terminate?” 1. Previous Gynaecological History 1.PCB = hot flushes. IMB. overweight. HypT – incl COC – breast Ca. cycle. other bleeding Smears – last smear & results Sexual – active?. occupation 2. infertility .Hx: Gynaecology History 1. hirsuitism. dyspareunia. jaundice. FUN 4. premature menopause = oligomenorrhoea. finances. contraception. alcohol. reduced libido. psych changes. age. Introduction 1. Menstrual – LMP. deep dyspareunia. ovarian Ca – smoking. infertility = dysmenorrhoea. cessation menses = puberty onset.

Ex: Gynaecological Examination & Smear 1. polyps. adnexae (?masses – size. bring heels to bottom and let knees fall” “ensure privacy & cover with drape” Abdominal examination - - 2. lesions) fix speculum take smear with spatula (rotate 360° both directions) smear on slide (both sides of spatula) fix slide immediately unfix & remove speculum (slowly. Bimanual Examination “internal examination to feel womb & ovaries” lubricate two fingers of gloves inspect vulva & labia insert fingers into vagina & place other hand on abdomen 1. but not painful” “have you gone to the bathroom” Expose “undress below waist. date) fixative (remove cap) 3. consistency. uterus mobility  pain 4. 4. gloves lubricant Cusco speculum Ayre’s spatula  cervical brush (postmenopausal) slide (label name. tender?) withdraw and inspect glove for any blood or discharge - 5. 6. lie flat. DOB. uterus size 2. Introduction Chaperone!! Consent & Explain “taking a smear from the neck of your womb looking for changing cells” “uncomfortable. Speculum Examination & Smear gloves assemble. mobile. close slightly & allow naturally close) dispose in bin 4. warm & lubricate speculum (not tip) part labia & insert speculum (vertical & then turn horizontal) identify & inspect cervix (erosions. Equipment 1. Finish Offer tissue to wipe Allow privacy to redress . uterus anteverted/retroverted 3. 2. 3. 5.

catheter bag & 2 gloves into sterile field + pour antiseptic solution into bowl.lubricate tip of catheter . Finish - - record volume of urine ensure comfortable . separate gauze for each clean) . saline-filled syringe catheter bag 3. lie flat.remove outer gloves 4. 4. antiseptic bowl.drape legs . Prepare patient . lubricant at edge. dirty hand holding labia) (front to back. Prepare equipment . 2 pairs gloves Foley catheter (12-14 French) catheterisation pack (urine pan. syringe at edge 2. bring heels to bottom and let knees fall” “ensure privacy & cover with drape” 2.inject saline to inflate balloon (ask if any pain) . drapes) antiseptic solution lubricant 10ml.attach catheter bag 4. 7. 2. 6. Wash hands & Double-Glove 3.place urine pan between legs .clean area with gauze & antiseptic twice (clean hand cleaning. Catheterisation 1. Introduction Chaperone!! Consent & Explain Expose “undress below waist. 5. Catheterise . Equipment 1.gently .gently retract until resistance . progressively insert while holding by plastic sleeve .Skl: Female Catheterisation 1. gauze.open catheter.open catheter pack aseptically . 3.

anticonvulsants 2. smoker (<15/day. clotting disorder (DVT.Com: Explain COC Pill 1.mechanism . Sexual History sexually active? previous contraception? reason for COC? previous experience or knowledge ( ovulation. cardiovascular. V& D 3. <35yo) 7. +FH breast cancer 2. antibiotics FH 1. Instruction start pack on first day of period same time every day for 21 days then 7 day break (period) if forget. first month of COC 7. mood changes (consult doctor if persist >3m) 6. Finish information leaflet offer alternatives if unsuitable or unmotivated . antibiotics 4. take within 12h of normal time important to remember!! S/E = weight gain. breast cancer. headaches. breast tenderness. COC Education . cancer) (clotting. acne. diabetes.  sperm entry. Contraindications - - - PMH 1.efficacy . hypertension 6. Problems reduced efficacy (condoms for 7 days) 1. STIs) 3. nausea. cancer 4.  implantation) (99% perfect use) (periods. Introduction 2. pregnant 2.benefits . focal migraine. forgetting pill >12h 2.risks 4. previous breast/ gynae. heart disease DH 1. +FH clotting disorders 5. breastfeeding 3. PE) 5.

benefits .pregnancy .infection . Cu IUD Education .  implantation) (98-99% effective) (no hormones or pills.Cu allergy 5.menorrhagia or undiagnosed PV bleeding .Com: Explain Copper IUD 1. Sexual History sexually active? previous contraception? reason for IUD? previous experience or knowledge? 3.mechanism . Instruction inserted first 14d of cycle after 7d no sex inserted by GP/family planning doctor using speculum through neck of the womb thread is left in vagina to check still in place lasts 5-8 years S/E = heavier periods. Problems expelled during period (encouraged to check thread) 7. spotting 6. Finish - - information leaflet offer alternatives if unsuitable .risks ( sperm entry. ectopic pregnancy) 4. Introduction 2. Contraindications .efficacy . very effective multip) (infection.

injection first 5d of cycle .re-inject every 12w . Finish - - information leaflet offer alternatives if unsuitable . Problems .S/E = irregular bleeding + weight gain. may need regular pregnancy tests 7.benefits (no hormones or pills. breast tenderness.  implantation) .efficacy (99% effective) . hidden) . Depot Injections Education . Sexual History sexually active? previous contraception? reason for Depo? previous experience or knowledge? 3. Contraindications pregnancy undiagnosed PV bleeding planned pregnancy in near future 5.if periods stop. Instruction .mechanism (( ovulation. Introduction 2.  sperm entry.risks (delayed return of fertility) 4.Com: Explain Depot Progestogen Injection 1. mood changes 6.

Instruction Pill    IUD  free. Education pill  contains progestogen  earlier started the more effective  95% effective <24h (85% <48h. consult if vomit within 2h) insertion - 6. GP. tips to remember taking pill) encourage protected sex (pregnancy & STIs) information leaflet . Contraindications pregnancy (need to be tested) 5.confidentiality concerns 2. Introduction . available from family planning clinic. Finish need for effective contraception (explain condom.Com: Explain Emergency Contraception 1. Sexual History reason + penetrative sex? sex last 72h? previous contraception? previous experience or knowledge? 3. Problems Failure = if no period. 60% <72h) copper IUD  prevents implantation in womb  can be inserted up to 5d  virtually 100% effective - 4. consult doctor for pregnancy test Contraception = use condom until next perod Ectopic pregnancy = consult doctor if abdominal pain 7. A&E & pharmacies 1/2 tablets to be taken immediately S/E = N&V (usually given anti-emetics.

Instruction 1. holding teat roll down shaft to base 6. check no damage 4. British Kite mark 2. oil-based lubricant . no contact before 2. Checks 1. ranges from 85-98%) (STI protection) 4. open carefully (no nails/teeth) 3. double condom. squeeze out air 5. Introduction 2.NO double use.Com: Explain Condom 1.emergency contraception  STI check if splits 6. dispose . Condom Education mechanism efficacy benefits (latex sheath over penis during intercourse) (98% perfect. Finish ask patient to repeat & demonstrate information leaflet . expiry date (quality guarantee) 5. Equipment 2 condoms model of penis information leaflet 3. position correct way on tip 5. hold base when withdrawing 7.

Syph) ♂ urine (G. Presenting Complaint ♀ 1. abnormal bleeding (PCB. HIV)  anal. blood sample (HIV. BV. Sexual History last sexual intercourse (LSI) + partners in last 3 months 1. partner (gender? regular? nationality? contact?) 3. frequency) 3.Hx: Genitourinary/Sexual History Introduction “reassure confidentiality & separate notes” “embarrassing questions. throat swab . abdominal pain 6. vulval lesion/rash/itch ♂ 1. smears – gravida? para? – last passed urine (>2h)? HepB vaccination (MSM)? – general health? – contraception. smell) 2. blood (Syph. urethral swab (G). dates 2. condom use previous STIs previous HIV test & result - 3. CSwab (G. IMB) 4. C. dyspareunia (deep/superficial) 5. antibiotics (current/recent) + allergies – IVDU. History Obs. History Male History Medical History Drug History Social History – contraception. genital lesion/rash/itch 2. normal?). type of sex (OI/AI/VI. LMP. colour. Finish “anything else you want to tell me that I haven’t asked about?” “anything worrying you?” * Contact Slip * Examination * Investigations ♀ urine (DM) . urinary symptoms (dysuria. age. vaginal discharge (duration. active/passive) 4. urinary symptoms 3. occupation 1. HVSwab (T. urethral discharge (or anal) 2.C). Can). DM). but necessary” name. Other History Gynae. menstrual (cycle. testicular pain 4.

transfusions. insurance) social support ? health advisor . Introduction . long-term onset to AIDS) (unprotected sex.Com: HIV Pre-Test Counselling 1. India) 4. HIV +ve 2. sexual assault 6. not AIDS test!!) (false negative from 3 month response to HIV infection) 5. Previous HIV Test date? result? (voluntary & informed) 3. HIV/AIDS Education HIV & AIDS transmission prevention (HIV viral infection. occupation. IVDU 5. vertical) (safe sex. homosexual or bisexual ♂ 3.Confidentiality 2. S America. HIV Test blood test window period 2 weeks for result (detects antibodies to HIV.Consent . occupational risk (sex worker) 7. HIV Risk Assessment personal or partner history: 1. Caribbean. Implications “what would you do if positive result?” disclosure (partner. high prevalence area (Africa. E Europe. sharing needles. safe injection) 4. blood products or transfusions overseas or before 1985 6.

location . occupation 2. menopause.colour .“anything worrying you?” . nipple tethering.“anything else you want to tell me that I haven’t asked about?” . duration & cyclicity .amount . spontaneous? + nipple inversion. age.onset. breast pain (mastalgia) .socrates . HRT – breast Ca (ages) – smoking. skin changes + previous history? 3. social support 4. Introduction consent name. Finish . finances. biopsy) . LMP & cycle length) – pregnancies. breastfeeding – COC. breast lump . Presenting Complaint 1.onset. imaging. duration & cyclicity 3.*Triple Assessment (clinical examination. nipple discharge . alcohol. Other History Medical History Gynae History Obs History Drug History Family History Social History – previous breast disease – menstrual (menarche.uni-/bilateral?.increase in size? 2. illicit drugs – accommodation.Hx: Breast History 1.

fixation .hand behind head . posterior. humeral) 3. nipples – retraction. smooth lump = single painless. tenderness 6. non-tender. shape 4. Breast . consistency 5. non-tender. position 2. skin – congested veins. inner/outer) . irregular lump + nipple discharge. peau d’orange skin 3. Finish * palpate infraclavicular & supraclavicular nodes * auscultate lungs Fibroadenoma Fibrocystic Change Breast Cyst Breast Carcinoma = single painless. soft. anterior.Ex: Breast Examination Introduction Chaperone Consent Expose (undress from waist upwards) 1. size 3. movement – nipple/lump tethering or asymmetrical contour changes (raise & lower arm . Paget’s disease of nipple 2. tender.lift & abduct arm (support & palpate with other hand) .systematic palpation (apical. peau d’orange + enlarged axillary nodes Lump 1.e. dimpling. upper/lower.systematic palpation (4 quadrants + tail i. smooth lump = multiple/single tender lumps = single/multiple painful. Inspection 1. Axillary Nodes . then press against hips) 2.squeeze nipple for discharge 2. tethering. nipple retraction. firm. Palpation 1. firm.