History taking in obstetrics&gynaecology

CHUWA S.P.
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 INTRODUCTION OF A PATIENT
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Name ……………………
Age ……………………
Religion………………….
Tribe …………………
Occupation …………..
Marital status ………..
Next of kin …………….
Residence………………
GPL…+… LNMP….EDD….. GA….
DOA and TOA (duration in the ward if admitted)
DOHT and TOHT
 Introduction ct….
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Next of Kin……….
Referral and reasons for referral…
Special circumstances
Post op patient – How many days post op
- Type of operation
- Indication(s) for operation
 Chronically ill patient – What is the condition
- for how long has she been sick
- On medication/or not, which medication?
 CHIEF COMPLAINTS
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Use patient’s own words – Avoid medical terminologies

Should appear in chronological order

May include new complaints identified during history

 HISTORY OF PRESENTING
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ILLNESS (HPI)
Amplification of symptoms – onset, progress, locality, radiation,

associating factors, aggravating and relieving factors

Possible causes and risk factors

Complications

Health seeking behaviour

Note: other parts of the Hx may be included here

 HPI ct
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Eg.
The pt was apparently well until …days ago when she
gradually/suddenly started experiencing headache: confined to../
generalized, type of headache, what makes it more worse, or
somehow improved by what??
What are some factors that may be associated with headache?
fever
When/what makes the headache improve-periodicity or relieving
factors
What is the situation now along the course of illness?
complications Blurred vision, blindness, confusion ,convulsions
 REVIEW OF OTHER SYSTEMS
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Review systems which were not affected and not exhausted
in HPI
RS – cough, DIB, chest pain or tightness, wheezes

CVS – awareness of heart beat,easy fatigability, difficult in lying flat,

CNS – Headache, dizziness, convulsion, LOC, blurred vision
UT - painful, difficult, or frequency, of micturition, Blood in urine
GIT – nausea, vomiting, diarrhea, constipation, color of the stool
MSS – joint/muscle pain, joint stiffness or swelling, general body
weakness
 PAST OBSTETRIC HX
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Narrate each pregnancy clearly

Age, sex of the child, mode of delivery, weight of the baby, alive or dead
Each pregnancy establish problems during pregnancy, labor and
delivery or postpartum period
Current pregnancy give ANC history or mention duration since delivery
Abortion: year of occurrence, type of abortion-spontaneous or induced,
gestation age, any complications, any treatment given?
 ANTENATAL HISTORY(Index pregnancy)
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Booking (1st visit ) Blood group
Blood Pressure Deworming
Haemoglobin level Haematenics (state their use
Any risk factor throughout pregnancy)
PMTCT status Total No.of visits
VDRL Any complications detected during
ANC
Doses of SP give
 MENSTRUAL HISTORY
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Age at menarche

Length of cycle

Regular or irregular

Duration of menstruation(Blood flow)

Nature and amount of blood

Amount of blood (No. of sanitary pads used per day )

Any Pain during menstruation?

 GYNAECOLOGICAL HISTORY
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AFTER REVIEW OF OTHER SYSTEM THERE IS NO HX OF INDEX

PREGNANCY YOU COME TO MENSTRUAL HISTORY THEN
GYNAECOLOGICAL HX.
 GYNECOLOGICAL HISTORY
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Age at sexual debut

Pain during coitus
Any abnormal vagina bleeding or discharge
Vulval or vagina Itching
Any history of genital ulcer??-pain,discharge,smell
History of any gynecological procedure or operation
Hx of contact bleeding
History of contraception (type, duration, doses, when was the last
dose, any complications, reasons for stopping)
 PAST MEDICAL HISTORY
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These are medical conditions other than obstetrics or gynaecology

Any chronic illness

No of admissions

For each admission – reason, diagnosis, treatment, no of days in the ward

Drug history

Food or drug allergy

History of BT

History of surgery
 SOCIAL AND FAMILY HISTORY
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Details of occupation
Details of marital status
No of partners
No. of siblings
H/o alcohol consumption or cigarette smoking
H/o diseases running in the family DM, HT, SCD
 Dietary history
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Types of meals- proteins, carbohydrates, vitamins, etc,amount of water

per day (glasses per day e.g > 8 glasses or 1.5L)
Number of meals per day
Comment on the quality and quantity
 Summary 1
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Name…………
Age …………
GPL, EDD, GA
CC …………..
Important positives
Important negatives
 Progress in the ward
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Duration

Investigations

Any medication given

Improvement of symptoms and signs

 IMPRESSION/PROVISIONAL DX
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1…………
2………… or
3………….
 PHYSICAL EXAMINATION
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GENERAL EXAMINATION:
General state of health- ill looking or not
Level of consciousness.
Orientation to TPP
Pallor, jaundice
Hair distribution
Peripheral oedema
Finger clubbing
Peripheral LN
 VITAL SIGNS`
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Pulse-beats/min, volume, regularity, synchronicity with other
peripheral pulses,
Respiratory rate-breaths/min-regularity
Temperature (Febrile/afebrile)
Blood Pressure……mmHg
 PHYSICAL EXAMINATION ct……
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SKIN: Observe for dehydration:

Dehydration
Lesions
Surgical/Traditional marks
HEAD AND NECK: Inspect and palpate
Cervical LN
Any masses or unusual neck pulsations
Palpate the trachea for any deviation
Thyroid gland
 PHYSICAL EXAMINATION ct……
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RESPIRATORY SYSTEM&CHEST:
Inspection
Palpation
Percussion
Auscultation
All for the lungs and the chest.
 PHYSICAL EXAMINATION ct……
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BREASTS:
Inspection & Palpation of both breasts
Special attention on:
 the state of breasts during pregnancy
Any pain
Any secretions from the breasts
Any masses
Palpate for axillary LN
 PHYSICAL EXAMINATION ct……
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CVS
Inspect and palpate for the carotid pulsations
Jugular venous pulsations
Apex beat
Heart sounds: (a) Any abnormal heart sounds,(b) Any murmurs
MSS
Examine :
Hands
Arms
Shoulders
Neck
Joints
Report any MSS abnormalities
 PHYSICAL EXAMINATION ct……
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ABDOMINAL EXAM.
Inspection
Palpate
Percussion
Feel for the kidneys, abdominal aorta and its pulsations
Pelvic examination:
 Examination of a pregnant woman
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INSPECTION:
Contours
Presence of:
Surgical scars
Traditional marks
Dilated veins
Striae Gravidarum
Hernias
 PALPATION OF A PREGNANT UTERUS
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The LEOPOLD’S Maneuvers :

1st maneuver (Fundal height)
2ndManeuver,lateral grip (Lie of the foetus)
3rd Pawlick’s (Presentation)
4th Maneuver,Pelvic grip (Descent
Foetal heart sounds-beats/min, regularity
Percussion: looking for, free fluid, shifting dullness, fluid thrill
Auscultation:Specifically for foetal heart beats counted for one full
minute.
 1st Maneuvers
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The palpation is done facing the patient’s face.

The whole of the fundal area is palpated using both hands

Fetal pole which can be podalic or cephalic occupying the uterine fundus
Podalic (Breech) is described as large (broad), nodular mass

Cephalic is described as a hard and round and more mobile and ballotable.
 2nd MANEUVER (LATERAL GRIP)
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Its done to determine the lie.

Facing the patient’s head, place hands on either side of the top of the
uterus and gently apply pressure.

Move the hands and palpate down the abdomen

One side will feel fuller and firmer – this is the back. Fetal limbs may be
palpable on the opposing side
 2nd MANEUVER (LATERAL GRIP)…
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Back is hard, resistant structure (smooth curved and resistant feel).

Fetal extremities is felt as numerous small irregular mobile parts (empty and
there are small knob like irregular parts).

The position of the anterior shoulder is to be sought for (It forms a well-
marked prominence in the lower part of the uterus above the head. It may be
placed near the midline or well away from the midline.)
 3RD MANEUVER (PAWLICK’S GRIP)
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The examination is done facing toward the patient’s face.

Palpate the lower uterus (below the umbilicus) to find the presenting part.
The overstretched thumb and four fingers of the right hand are placed over the
lower pole of the uterus keeping the ulnar border of the palm on the upper
border of the symphysis pubis.
When the fingers and the thumb are approximated, the presenting part is
grasped distinctly (if not engaged) and also the mobility from side to side is
tested.
 3rd MANEUVER (PAWLICK’S GRIP)
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If the presenting part is not engaged do not perform the fourth maneuver
Firm and round signifies cephalic, soft and/or non-round suggests breech. If
breech presentation is suspected, the fetal head can be often be palpated in the
upper uterus.
 3rd MANEUVER (PAWLICK’S GRIP)
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Firm and round signifies cephalic, soft and/or non-round suggests breech. If
breech presentation is suspected, the fetal head can be often be palpated in the
upper uterus.
Ballot head by pushing it gently from one side to the other.
Fetal engagement refers to whether the presenting part has entered the bony
pelvis.
 3rd MANEUVER (PAWLICK’S GRIP)…
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Assessment of engagement/level. ie
If you are able to feel the entire head in the abdomen it is 5/5th’s
palpable (not engaged)
If you are not able to feel the head at all abdominally it is 0/5th’s
palpable (fully engaged)
When 2/5 or less, this means that the head is engage , and by vaginal
examination , the lowest part of vertex has passed or is at the level of
ischial spines.
 4TH MANEUVER (PELVIC GRIP)
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The examination is done facing the patient’s feet

Four fingers of both the hands are placed on either side of the midline in the
lower pole of the uterus and parallel to the inguinal ligament. The fingers are
pressed downward and backward in a manner of approximation of finger tips
to palpate the part occupying the lower pole of the uterus (presentation). Note
how much of the head is palpable – if the entire head is palpable, the fetus is
unengaged.
 Examination of a pregnant woman ct…
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PALPATION: Superficial followed by deep

Pain
Masses
Liver
Spleen
Kidney
Signs of peritonitis
 VULVAL EXAMINATION
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Inspection
Hair distribution
Vulval skin
Look at the perineum for scars/tears
Gently palpate the labia inspect the urethra
Look for any:
discharge,
prolapse,
ulcers,
 warts
 SUMMARY 2
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Should include:
1. The history
2. Clinical findings
3. Make it short and clear. Mention only the relevant information
4. Eg.Mrs M.K P5 A0 L5 45 years c/o…………………………….?
……………………………….?
……………………………….?
On physical exam the findings were…………….
Provisional diagnosis……………………………….
DDX 1……………………………………………….
2…………………………………………………
 INVESTIGATIONS
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List down your investigations:Start with the most basic and reliable
tests
E.g.
FBP,
Urinalysis etc.
 Treatment&Prevention

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Follow the correct RULES of prescription

Give the correct preventive measures to that specific sickness the
patient presents with.
Thank you
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