Medical Student Sharing: history

HISTORY

Patient identification

1. Name

2. Age

3. Ethnic

4. Lady

5. Occupation

6. Address

7. Date of admission and clerking

8. Informant

9. Gravida

- No. of pregnancy irrespective of the outcome

10. Para

- No. of delivery of ≥ 24 wks of gestation / > 500g (including stillbirth)

- Twins are counted as 2

e.g: never pregnant before G1P0. If she delivered twins & come back next time at

12 wks, she will be G2P2 (twin)

- If abortion (delivery < 24 weeks / < 500g), put ‘+ number of abortion’

e.g: If abortion for 2 times and now she pregnant, she will be G3P0+2

*miscarriage occurred by accident, abortion occurred by planned surgery

11. Last menstrual period (LMP)

- 1^st day of last menses (ask hari pertama tak boleh sembayang)

- LMP reliable must fulfil Naegele’s rule:

* Sure of date

* Regular menstrual cycle 28-30 days

* Not on breastfeeding within 2 mths

(If exclusively breastfeed, ovulation will not start in 1^st 3^rd month; if not

exclusively, ovulation will occur at the 3^rd month)

* Not on hormonal therapy within 3 mths

(mention the Naegele’s rule in history to see one is fulfill

- If LMP not reliable:

* Ask about early U/S (<20w)

# 1^st trimester: difference 1 wk;

2^nd trimester: difference 2 wk

3^rd trimester: difference 3 wk

# If the scan date is corresponding to the EDD, use EDD

# If not corresponding, use the rEDD

# POA that is counted from rEDD should be presented as POG (period of gestation)

Mention date for each U/S

For U/S 1^st trimester is the most accurate reading the discrepancy of rEDD compared to real date of delivery is 1 week.

For 2^nd trimester is 2 weeks discrepancy.

For 3^rd trimester is 3 weeks.

12.

Other ways for dating:

- UPT in dilution (1^st positive 6-8wk)

- quickening

- uterine size corresponding to date

- histopathology (presence of

chorionic villi- either passed out

spontaneously or from curettage

specimen)

Expected date of delivery (EDD)

- LMP + (9 moths 7days)

13. Periods of amenorrhea (POA)

- counted from LMP to date of clerking

- present as ?weeks ?days

1 month= 4w + 2 days

2 months= 8w+ 5 days

3 months= 13w

(prof adibah: every 3mth- add 1 week (3x4+1=13))

Comment:

The LMP is ___. It fulfils the Naegele’s rule. U/s was done at___ weeks which is corresponds to the EDD, therefore the EDD is___/ not correspond to EDD, therefore, the rEDD is___

* u/s scan: normal EFW

- 24 wk: <1kg

- 28 wk: 1.4-1.8kg

- 32 wk: 2kg

- 36 wk: 2.4kg

* normal weight gain:

- 1^st 5mths: 0.5kg/mth

- 2^nd 5 mths: 0.5kg/wk

Chief complaint

- Complaint + duration

History of presenting illness (HOPI)

- ask about chief complaint or any related question (associated sx/ risk factors/ cx)

- at the end of HOPI, ask about:

* is patient in labour ?

# contraction pain (how many times in 10mins? each contraction last for how long?

regular? ↑ frequency and intensity?)

# show- blood stained mucus passed PV

# leaking liquor

* fetal movement (good or ↓?)

(ask the patient to count how long for fetal kicks for 10x, look for the pattern of time

completion- see the FKC)

FKC is a chart given at 3^rd trimester. Counted everyday from 9am-9pm. 1 KICK= 1 kick, or multiple kicks at one time, or 1 rolling. When mother sensed there are 10 kicks in total, she will made a tick at the time of completion of 10kicks(eg. Usually 1pm) at the chart. Another version is fast Fetal Kick Chart which only required counting 10 kicks in 2 hours, for busy mother. If kicks is less than 10 in a day(from 9am-9pm) indicative of reduced fetal movement.

London used Cardiff county method.

Fetal movement reduced, possible causes:

1. Mother is fatigue, (involved in strenuous activity), less energy provided to baby

2. Infection, if mother is having fever, fetal temperature is 1 degree Celsius more than the mother

3. Trauma, in kampong, mother rode motorcycle or multigravida mother, the abdomen was kicked by her naughty children in fight

4. Mother took sedatives

5. Mother is malnourished, can be due to taboo(wrong thoughts about some food could cause harm to baby), nausea and vomiting(cannot eat much)

6. Mother went for lenggang perut, reposition of baby by traditional healer causing cord around neck

7. Baby is hypoxic, placenta insufficiency

8. Increased in amniotic fluid or uterine contraction (cannot sense the kicks)

9. Sometimes can be just due to mother too busy and not correctly count or too worried as she had experienced miscarriage or similar experience in previous pregnancy

10. IUD is usually dued to abruption placenta, no kick at all.

Hx should mention –ve trauma, -ve sx of infection(eg. UTI sx), -ve goin to traditional healer, and diet balance.

**no need systemic review if all +ve n –ve sx had been illicited

- briefly about what is done in hospital

Comment:

She missed the period for __weeks. She did the UPT and was found to be +ve

Systemic review

History of presented pregnancy

Present HOPP in sequence, 1^st, 2^nd, then 3^rd trimester

- suspect pregnancy

* why- missed period? Quickening? Abdominal distension?

* when?

Missed period state when, at 6^th week since last period? Did she do UPT herself? When UPT is +ve, did she go to the clinic immediately, if no state why?

*UPT can only be positive at 2 w after ovulation which means 1 mth after the last period

- confirm pregnancy

* when? where? who?

* u/s?

Which clinic?

- booking= 1^st antenatal check-up

* when? where? (bila ambil kad merah?)

* physical examination

ANC:

- Monthly till 28 weeks

- Fortnightly till 36 weeks

- Weekly till delivery

# height, weight, BP, fundal height

* investigations

# blood test- blood group, rhesus, Hb

Comment:

- blood and urine test were done

and were normal

- screening test were not reactive

- mOGTT was done at __wk with

reading __/__

- BP, height and weight were

normal

- For the subsequent ANC, u/s

scan and fundal assessment

show fetal growth correspond to

gestational age and amniotic

fluid is adequate, no congenital

abnormality detected

# Urine test- glucose, protein

# VDRL (reactive/non-reactive), HIV

- mOGTT done? Indication? When? Result?

- subsequent antennal check-up

* when- patient attend all ANC follow schedule?

* parameter- normal?

* weight gain

* BP

* Uterine size

* Hb

* Urine glucose and protein

* U/S done?

- When?

- Any abnormalities

Things to be stated from booking: Height, weight, bp, urine protein n glucose, hb, blood group, rhesus, VDRL, Hep B, HIV

(try use clerkin in osce/long case, ask the patient whether she remembered the parameters instead of copy from the redbook, if she cant remember, ask if doc comment anythg, any abnormalities)

Antenatal checkup is done every 4w in 1^st tri, every 2 w in 2^nd tri and every week in 3^rd tri

10-12w : correct dating (dating scan)

20-22w : to detect any congenital abnormality

28w : to detect location of placenta

32w : to final confirm the location of placenta

Quickening:

- Primigravida= 18-20w (5 months)

- Multigravida= 16-18w (4 months)

- Quickening- 1^st fetal movement

* When?- bila berasa bayi pertama kali bergerak?

* ↑ intensity and frequency?

- Signs and symptoms of pregnancy

* nausea and vomiting

* breast discomfort/engorgement

* frequency of urination

* constipation

* ankle edema

* backache

- immunization:

* anti-tetanus toxoid (ATT) - IM 0.5mL

# Primigravida

- 1^st dose after quickening (20-24w)

- 2^nd dose - 4-6 weeks after 1^st dose (24-28w)

- latest 4 wks before delivery

# Multigravida

- One dose only after quickening (usually at 32-36w)

* Hepatitis B (3X)

* Rubella (usually during school times)

Past obstetric history (POH) – no need present if primigravida- only marital status

- Marital status

* When married?

* Married at age?

* 1^st married? the only married? (related with pregnancy induced hypertension)

* Consanguineous married? (related with chance of genetic disease transmission)

- no of children? How many boy and girl?

- for each pregnancy:

* age

* sex

* where deliver- hospital? Clinic?

* when- full term? POG if preterm?

* method of delivery

# spontaneous vaginal delivery

# induced vaginal delivery: Postdate, PIH, GDM, heart disease etc

# assisted vaginal delivery- forceps? Vacuum? Why? Prolonged labour, heart dz etc

# lower segment caesarean section- elective/emergency?

(a) why? where? POG?

(b) duration of staying in wad- 5 days if no Cx

(d) any VBAC after the caesarean section?

* ask the indication except SVD

* birth weight

# low birth weight < 2.5kg

if all deliveries are normal, summarize ‘no AP,IP,PP Cx’ at the end of presentation of POH

# big baby > 4.0kg

* antepartum Cx- APH, placenta praevia,

* intrapartum Cx- poor progress, fetal distress

* postpartum Cx- PPH, lochia changes, fever

* breastfed till when?

# normally for 2 yrs (exclusive 6 months)

# if stop early/bottled feeding-why?

- if abortion

* POG?

* why?- spontaneous? Trauma?

* signs and symptoms before abortion.

* dilatation and curettage (D&C) done?

# D&C- incomplete abortion

# no D&C- complete abortion

- if >5 children

* Summarize all the uneventful deliveries (FTSVD with no Cx)

* eldest what age? youngest what age? birth spacing?

* all born through FTSVD with no AP, IP, PP Cx

* BW range

* breastfeeding

* developmental growth

* Mention the abnormal deliveries separately

- spacing

* good spacing- 2 years apart

* abnormal-> 6 years, why? contraception? Subfertility?

- contraceptive method:

* OCP/ injection/ implantation

* IUCD

* condom

For complication of C-sec,

1. Anesthesia, half or full

2. Bleeding? Any blood transfusion

3. Injury to organ, bladder? Rectum?

4. Post-op, well?

Csec: indication to do, complication, venue which hospital

Past Gynaecology History (*combined together and state gynae hx)

- menstrual history

* when attain menarche (1^st menstrual period)? Normal 9-16 y/o

* menstrual cycle

Written as:

Age of menarche flow

cycle

# regular/irregular

# cycle- normal 21-35 days

# flow- normal 2-8 days

# heavy flow- normal 1^st-3^rd day

# pad used-average blood loss 30ml

# problems

(a) dysmenorrhoea- painful menstruation

(b) menorrhagia- prolonged and increased menstrual flow (blood loss>80ml)

(d) postcoital bleeding

(e) dyspareunia- painful coital

- pap smear history

* how many times?

* when was the last one?

* result normal?

Past medical and surgical history

- hx of chronic illnesses: HPT, DM, heart disease, asthma, TB

- any surgery procedure done before?

Family history

- siblings and parents- health problem

- family hx of HPT, DM

- Family hx of twins preg or congenital abnormality

Personal and social history

- education level

- husband’s age, occupation (type, work place, daily come back), income

- house condition: stair, toilet and etc

- how frequent husband visit her?

- who take care of her children during admission?

- how does she contact her children?

- smoking? alcohol?- both husband and pt

Transportation at home, some pregnant lady ride motorcycle

Nearest clinic from home? Convenient to checkup?

Drug history

- hematinics

* iron- besi (T. ferrous fumarate 200mg contain 60mg iron)

* folate- ubat kuning kecil (5mg/tablet)

* vitamin B12 &C

- over counter drugs: Obimin (contain iron, folate, Vit B12 and etc)

- traditional medication

- allergy/ side effect

Obimin contained all four, iron(ferrous fumarate, folic acid, B12 and Vit C)

Obical include obimin plus calcium

The all four are enough for what required for mother

Dietary history

- normal balance adult diet

- allergy

- if patient is diabetic, details diet history are needed, including dishes for every meals,

who give the advice? was pt understand, give eg of food?

Summary

Name/ age/ race/ gravida/ para/ POA/ chief complaint/ complication/risk factor/ management that been given/ in labour or not/ fetal movement

lightening: primigravida at 34 wk when head enter the pelvic brim (mother will felt sudden relief of SOB or breathing discomfort)

PHYSICAL EXAMINATION

Before start

- introduce pt to dr

- introduce dr to pt

- ask permission from pt and ask for chaperone

- position: Lying flat

- pt comfortable? With both hands at the side of body

- pt can sit upright if she had sign of cardiac disease or grossly enlarged uterus (cause

splitting of diaphragm)

General examination

- Inspection:

v Comfortable, lying flat/ propped up supported with one pillow

v Alert and conscious

v Well orientated to time, place and person

v In pain, in respiratory distress

v Hydrational and nutritional status

v Gross deformity

v Abnormal movement

v Attachment

v Height : <148cm and small shoe size→ smaller pelvic capacity→ CPD

v Weight

v Hand:

· Warm/cold, dry/sweat

* Mother with HPT is not advice to wear ring (edema)

Pale

· Palmar erythema (↑ estrogen level)

· Koilonychias (iron deficiency)

· Peripheral cyanosis

· Clubbing

· Capillary refilling

· Collapsing pulse (pathological/physiological d/t hyperdynamic circulation)

v Vital sign:

· Pulse rate, volume and rhythm

· BP (sitting position or prop up 45 degree) pregnancy induced HPT dx after 20 w with measurement of high bp in 2 occasions

· RR

· Temperature

v Neck:

· JVP- if indicated

· Thyroid swelling (normal for pregnant mother as they usually experience iodine deficiency)

v Face and eyes:

· Jaundice in sclera

· Pallor on conjunctiva

· Mouth, lips and tongue:

- Tongue: Moist/ Coated

- Oral hygiene

- Central cyanosis

- Glossitis- nutritional deficiency

- Angular stomatitis- nutritional deficiency

- Oral thrust- candidiasis

v Leg:

· Pitting edema

· Dilated vein

v Examine reflex and fundoscopy for hypertensive patient

Specific examination

(a) Before start:

v Ask permission

v Exposure- xyphisternum to symphysis pubic (not nipple line to mid-thigh!)

Prof Nora- expose from lower border of bra to pubic symphysis (ask chaperone or examiner to expose the patient)

(b) Inspection:

v Abdomen is distended with gravid uterus evidenced by

· Linea nigra

· Striae gravidarum-red, present stretch mark

· Visible fetal movement

(Prof Nora- show the findings by pointing it with thumb)

v Striae albicans- white, previous stretch mark

v Move symmetrically with respiration

v Umbilical: Centrally located and Inverted/flat/everted

v Dilated vein

v Surgical scar

· Laparoscopy: Umbilical; Small, easy to miss

· LSCS: Transverse suprapubic/ pfennential scar

· Upper segment caesarean section: Paramedian

* If there is scar

- site, size, shape

- well heal/infected/keloid

- surrounding skin- pigmentation, redness, swelling, ulceration, discharge

- look for scar tenderness during palpation. (palpate around the scar to look for

uterus tenderness)

v Inguinal cough impulse

v Superficial palpation: Soft, tenderness

(comment- the abdomen is soft and not tender)

v Deep palpation: Contractile uterus

(comment- the uterus is soft, not tender and not irritable)

(if present of contraction- palpate at the fundus and time the contraction)

(don’t perform deep palpation for Prof Nik Haslina)

v Fundal height

· Symphysiofundal height

- Palpate the fundus using ulnar border of left hand from xiphisternum

12w- just above suprapubic

22w- umbilicus

36w- xyphisternum

- Put the tape with inch scale on top

- Palpate for symphysis pubic (midline, 1^st bony prominent)

- Measures in cm (1w= 1cm)

· Clinical fundal height (some dr no need present this…)

- Estimate how many finger breadth the fundal palpable below xyphisternum/above

umbilical

(don’t use finger to count- Prof Nik Haslina)

- Count fundal height (1w=1cm)

* After 36w- below xyphisternum (less 1cm for every week) but there is fullness of

flank and cannot get below the costal margin)

* Mention as ‘’fundal height is __ weight’’

* Fundal height corresponding to POA?- allow +/- 2cm

Example 1: pt in 38w POA

The symphysiofundal height was 33cm. The fundus was palpable one finger breath below xyphisternum. There was fullness of flank and I could not get below the costal margin. The clinical fundal height was 38w which was corresponding to the POA.

Example 2: pt is in 34w POA

The symphysiofundal height was 34cm. The fundus was palpable 1 finger breath below xiphisternum. There was no fullness of flank and I was able to get below the costal margin. The clinical fundal height was 34w which was corresponding to the POA.

Notes:

- symphysiofundal height is not very reliable in assessing the uterus size if you only see your patient for the 1^st time because it is influenced by other factors, e.g. obese and thin, amount of amniotic fluid, fetal weight.

- symphysiofundal height is useful when you f/u the patient during antenatal visit. You can assess the ↑ in symphysiofundal height compared to last visit.

Pawlick grip:

- can not performed by medical student

- using thumb and pointing finger to grip at

the fetal head

(d) Grips (Leopard’s)

- Fundal grip

· face patient

· feel the fundus using both hand

- lateral grip

· face patient

* causes of head not engaged:

- placenta praevia

- polyhydramnios

- pelvic mass/ uterus mass (fibroid)

- CPD

fix one hand and palpate with another hand

- pelvic grip

· face patient’s leg

· feel with both hands

· feel for engagement

- comment on:

- singleton/ twins

- Lie- relation of long axis of fetus to the long axis of uterus

* longitudinal (normal), transverse, oblique

- Presentation- pole of fetus that presents on pelvic brim

* cephalic (normal), breech

- Engagement (for cephalic presenting)- the largest presenting part enter the pelvic brim

· If ballotable= not engaged

· use 5 fingers to measure

· if 3 fingers palpable per abdomen= 3/5th palpable

· 2/5th palpable per abdomen= engaged

- liquor volume- clinically adequate?

- fluid thrill if excessive liquor

- estimated fetal weight

Polyhydramnio: when palpate hand need to go deep more than 8cm to feel fetal

Oligo: hand less than 2cam

· Head- round, hard, ballotable

· Buttock- broad, firm, not ballotable

· Fetal back- smooth, firm, continuous

· Fetal parts- bulging

· Excessive liquor (large fundus, can’t feel fetal parts, + fluid thrill)

· Reduced liquor (tense abdomen, easy to feel fetal parts, small fundus)

Reason oligo: HPT, placenta insufficient

(e) Auscultation:

· For fetal heart sound-present/ not present

· Use pinard (don’t stress on look at patient face,as long as

· Comfortable n hands off pinard)

· Listen at anterior shoulder

· Dont press too hard and both hands off when listen!!

· Must count HR (normal 120-160)

(f) Complete examination with:

· Per vaginal examination (C/I- in PV bleeding/ leaking liquor)

· Breast examination: important for breastfeeding

· l/n examination

· Others systems if relevant

Present:

- From inspection, the abdomen was distended with gravid uterus evidenced by presence of linea nigra, striae gravidarum, visible dilated vein and fetal movement. There were __ striae albican and ___ scar (type, length, well healed/not, sign of inflammation, tenderness). The umbilicus is centrally located and ___

- On superficial palpation, the abdomen is soft and not tender.

- On deep palpation, the uterus is soft, not tender and not irritable.

- The SFH was ___ cm correspond to POA/POG. The fundus is palpable __FB below xiphesternum. __ fullness of flank and ___ get below costal margin. The clinical fundus height is ___wk

- There is ___ fetus with ___ presentation, ___ lie. The fetal back is at maternal __side and fetal part at maternal __ side. Fetal head is __/5^th palpable, __ engaged. Fetal movement __ felt and __ uterus contraction. Liquor is clinically __. FW is __kg (range with interval 0.2)

- Fetal heart was heard at __ quadrant using Pinard and heart rate is __ bpm

# Prof Adibah: evidence of gravid unterus: only fetal movement and fetal heart

Investigate

U/S
: check anencephaly, cord around neck, growth restriction

CTG: Fetal distress: check whether HR normal, whether there is acceleration (normal)

Urine FEME: check UTI

FBC: ANEMIA, INFECTION

Placenta blood flow, check using doppler ultrasound,

Normal position of placenta, upper segment

Mx for reduced fetal mov:

Admission, bedrest, fetal kick chart, CTG daily

Medical Student Sharing

Sunday, August 7, 2016

OBS HX TAKING (WHY I CLERK?) [note to myself]

Monday, January 19, 2015

Notes on obstetrics history taking and physical examination (adapted to culture in Asia)