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)

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

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 – last cervical smear & result, urinary symptoms
- Medical History – HypT, DM, DVT/PE  SC
- Drug History – incl. supplements, diet
- Family History – PET, DM, DVT/PE + multiples + hereditary disorders
- Social History – 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)
Ex: Obstetric Examination

Introduction
- Chaperone !!
- Consent
- Expose abdomen (above fundus to pubic hairline)
- Position comfortably

General Examination
1. BMI
2. Hands (radial pulse, palmar erythema)
3. Eyes (anaemia)
4. Skin (spider naevi, chloasma gravidarum, pigmentation & freckles)
5. Heart (flow murmur)
6. Breasts (fullness, areolar pigmentation, Montgomery’s tubercles, nipples)
7. Legs (varicose veins, peripheral oedema)

1. Inspection
1. distension
2. pigmentation (linea nigra, striae gravidarum)
3. scars (transverse suprapubicPfannensteil, laparoscopic)
4. fetal movements

2. Palpation
1. SFH – symphyseal-fundal height
– SFH (2cm) approximates to dates (weeks)
2. Lie – direction fetal spine with respect o. long axis of uterus
– longitudinal, oblique, transverse
3. Presentation – cephalic/breech if longitudinal (head small & hard)
4. Engagement – ballotable presenting part?
– fifths of head palpable above pelvic brim
+ Fetal Movements
+ Liqour Volume
- ease in palpating fetal parts, SFH size
- polyhydarminos/oligohydraminos

3. Auscultation
- Fetal movments?
- SonicAid Doppler / Pinard stethoscope
(placed at position of fetal thorax)

Finish
- Recover patient & thank
(a) Blood Pressure Measurement

- inform possible discomfort & ask if resting last 5 mins

- check sphygmomanometer (set to 0 mm.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, mid-stream sample
- inspect sample (cloudy, bilirubiniruia, haematuria)
- immerse dispsitck
- wait 10s
- hold horizontally comparing to bottle
UTI = + nitrites, leukocytes, blood, protein
PET = ++ protein
DM = + glucose, ketones
Hx: Gynaecology History

1. Introduction
1. consent
2. name, age, occupation

2. Presenting Complaint

3. Previous Gynaecological History

1. Menstrual – LMP, cycle, menarche age, dyspareunia, other bleeding
2. Smears – last smear & results
3. Sexual – active?, contraception, previous STI
4. Urinary – incontinence, prolapse, FUN

4. Previous Obstetric History

- “Have you ever been pregnant before?”
- “Did you deliver the pregnancy? How many weeks deliver/miscarry/terminate?”
1. Year
2. Gestation
3. Outcome

5. Other History
- Medical History – DVT/PE, DM, jaundice, HypT
- Drug History – incl COC
- Family History – breast Ca, ovarian Ca
- Social History – smoking, alcohol, illicit drugs
– accommodation, finances, social support
6. Finish
- “anything else you want to tell me that I haven’t asked about?”
- “anything worrying you?”

Menorrhagia = duration, amount, dysmenorrhoea, IMB.PCB

Menopause = hot flushes, dyspareunia, reduced libido, psych changes, cessation menses
Amenorrhoea = puberty onset, weight loss, emotional upset, exercise, premature menopause
PCOS = oligomenorrhoea, overweight, acne, hirsuitism, infertility
Endometriosis = dysmenorrhoea, deep dyspareunia, heavy & frequent periods, infertility
Ex: Gynaecological Examination & Smear

1. Introduction
- Chaperone!!
- Consent & Explain
“taking a smear from the neck of your womb looking for changing cells”
“uncomfortable, but not painful”
“have you gone to the bathroom”
- Expose
“undress below waist, lie flat, bring heels to bottom and let knees fall”
“ensure privacy & cover with drape”
- Abdominal examination

2. Equipment
1. gloves
2. lubricant
3. Cusco speculum
4. Ayre’s spatula  cervical brush (postmenopausal)
5. slide (label name, DOB, date)
6. fixative (remove cap)

3. Speculum Examination & Smear

- gloves
- assemble, warm & lubricate speculum (not tip)
- part labia & insert speculum (vertical & then turn horizontal)
- identify & inspect cervix (erosions, polyps, 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, close slightly & allow naturally close)
- dispose in bin

4. 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. uterus size
2. uterus anteverted/retroverted
3. uterus mobility  pain
4. adnexae (?masses – size, consistency, mobile, tender?)
- withdraw and inspect glove for any blood or discharge

5. Finish
Offer tissue to wipe
Allow privacy to redress
Skl: Female Catheterisation

1. Introduction
- Chaperone!!
- Consent & Explain
- Expose
“undress below waist, lie flat, bring heels to bottom and let knees fall”
“ensure privacy & cover with drape”

2. Equipment
1. 2 pairs gloves
2. Foley catheter (12-14 French)
3. catheterisation pack (urine pan, antiseptic bowl, gauze, drapes)
4. antiseptic solution
5. lubricant
6. 10ml. saline-filled syringe
7. catheter bag

3. Catheterisation
1. Prepare equipment
- open catheter pack aseptically
- open catheter, catheter bag & 2 gloves into sterile field
+ pour antiseptic solution into bowl, lubricant at edge, syringe at edge
2. Wash hands & Double-Glove
3. Prepare patient
- drape legs
- place urine pan between legs
- clean area with gauze & antiseptic twice
(clean hand cleaning, dirty hand holding labia)
(front to back, separate gauze for each clean)
- remove outer gloves
4. Catheterise
- lubricate tip of catheter
- gently , progressively insert while holding by plastic sleeve
- inject saline to inflate balloon (ask if any pain)
- gently retract until resistance
- attach catheter bag

4. Finish
- record volume of urine
- ensure comfortable
Com: Explain COC Pill

1. Introduction

2. Sexual History
- sexually active?
- previous contraception?
- reason for COC? previous experience or knowledge

3. COC Education
- mechanism ( ovulation,  sperm entry,  implantation)
- efficacy (99% perfect use)
- benefits (periods, acne, cancer)
- risks (clotting, cardiovascular, breast cancer, STIs)

4. Contraindications
- PMH
1. pregnant
2. breastfeeding
3. previous breast/ gynae. cancer
4. clotting disorder (DVT, PE)
5. hypertension
6. smoker (<15/day, <35yo)
7. focal migraine, diabetes, heart disease
- DH
1. anticonvulsants
2. antibiotics
- FH
1. +FH breast cancer
2. +FH clotting disorders

5. Instruction
- start pack on first day of period
- same time every day for 21 days then 7 day break (period)
- if forget, take within 12h of normal time
- important to remember!!
- S/E = weight gain, headaches, nausea, breast tenderness, mood changes
(consult doctor if persist >3m)

6. Problems
- reduced efficacy (condoms for 7 days)
1. forgetting pill >12h
2. V& D
3. antibiotics
4. first month of COC

7. Finish
- information leaflet
- offer alternatives if unsuitable or unmotivated
Com: Explain Copper IUD

1. Introduction

2. Sexual History
- sexually active?
- previous contraception?
- reason for IUD? previous experience or knowledge?

3. Cu IUD Education
- mechanism ( sperm entry,  implantation)
- efficacy (98-99% effective)
- benefits (no hormones or pills, very effective multip)
- risks (infection, ectopic pregnancy)

4. Contraindications
- pregnancy
- infection
- menorrhagia or undiagnosed PV bleeding
- Cu allergy

5. 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, spotting

6. Problems
- expelled during period (encouraged to check thread)

7. Finish
- information leaflet
- offer alternatives if unsuitable
Com: Explain Depot Progestogen Injection

1. Introduction

2. Sexual History
- sexually active?
- previous contraception?
- reason for Depo? previous experience or knowledge?

3. Depot Injections Education

- mechanism (( ovulation,  sperm entry,  implantation)
- efficacy (99% effective)
- benefits (no hormones or pills, hidden)
- risks (delayed return of fertility)

4. Contraindications
- pregnancy
- undiagnosed PV bleeding
- planned pregnancy in near future

5. Instruction
- injection first 5d of cycle
- re-inject every 12w
- S/E = irregular bleeding + weight gain, breast tenderness, mood changes

6. Problems
- if periods stop, may need regular pregnancy tests

7. Finish
- information leaflet
- offer alternatives if unsuitable
Com: Explain Emergency Contraception

1. Introduction
- confidentiality
- concerns

2. Sexual History
- reason + penetrative sex? sex last 72h?
- previous contraception?
- previous experience or knowledge?

3. Education
- pill
 contains progestogen
 earlier started the more effective
 95% effective <24h (85% <48h, 60% <72h)
- copper IUD
 prevents implantation in womb
 can be inserted up to 5d
 virtually 100% effective

4. Contraindications
- pregnancy (need to be tested)

5. Instruction
- Pill
 free, available from family planning clinic, GP, A&E & pharmacies
 1/2 tablets to be taken immediately
 S/E = N&V (usually given anti-emetics, consult if vomit within 2h)
- IUD
 insertion

6. Problems
- Failure = if no period, consult doctor for pregnancy test
- Contraception = use condom until next perod
- Ectopic pregnancy = consult doctor if abdominal pain

7. Finish
- need for effective contraception (explain condom, tips to remember taking pill)
- encourage protected sex (pregnancy & STIs)
- information leaflet
Com: Explain Condom

1. Introduction

2. Equipment
- 2 condoms
- model of penis
- information leaflet

3. Condom Education
- mechanism (latex sheath over penis during intercourse)
- efficacy (98% perfect, ranges from 85-98%)
- benefits (STI protection)

4. Checks
1. British Kite mark (quality guarantee)
2. expiry date

5. Instruction
1. no contact before
2. open carefully (no nails/teeth)
3. check no damage
4. position correct way on tip
5. squeeze out air
5. holding teat roll down shaft to base
6. hold base when withdrawing
7. dispose
- NO double use, double condom, oil-based lubricant
- emergency contraception  STI check if splits

6. Finish
- ask patient to repeat & demonstrate
- information leaflet
Hx: Genitourinary/Sexual History

Introduction
- “reassure confidentiality & separate notes”
- “embarrassing questions, but necessary”
- name, age, occupation

1. Presenting Complaint
♀ 1. vaginal discharge (duration, colour, smell)
2. urinary symptoms (dysuria, frequency)
3. abnormal bleeding (PCB, IMB)
4. dyspareunia (deep/superficial)
5. abdominal pain
6. vulval lesion/rash/itch
♂ 1. urethral discharge (or anal)
2. urinary symptoms
3. testicular pain
4. genital lesion/rash/itch

2. Sexual History
- last sexual intercourse (LSI)
+ partners in last 3 months
1. dates
2. partner (gender? regular? nationality? contact?)
3. type of sex (OI/AI/VI, active/passive)
4. condom use
- previous STIs
- previous HIV test & result

3. Other History
- Gynae. History – contraception, menstrual (cycle, LMP, normal?), smears
- Obs. History – gravida? para?
- Male History – last passed urine (>2h)? HepB vaccination (MSM)?
- Medical History – general health?
- Drug History – contraception, antibiotics (current/recent) + allergies
- Social History – IVDU,

Finish
- “anything else you want to tell me that I haven’t asked about?”
- “anything worrying you?”
- * Contact Slip
- * Examination
- * Investigations
♀ urine (DM) , HVSwab (T, BV, Can), CSwab (G,C), blood sample (HIV, Syph)
♂ urine (G, C, DM), urethral swab (G), blood (Syph, HIV)  anal, throat swab
Com: HIV Pre-Test Counselling

1. Introduction
- Consent (voluntary & informed)
- Confidentiality

2. Previous HIV Test

- date? result?

3. HIV/AIDS Education
- HIV & AIDS (HIV viral infection, long-term onset to AIDS)
- transmission (unprotected sex, sharing needles, transfusions, vertical)
- prevention (safe sex, safe injection)

4. HIV Test
- blood test (detects antibodies to HIV, not AIDS test!!)
- window period (false negative from 3 month response to HIV infection)
- 2 weeks for result

5. HIV Risk Assessment

- personal or partner history:
1. HIV +ve
2. homosexual or bisexual ♂
3. high prevalence area (Africa, Caribbean, S America, E Europe, India)
4. IVDU
5. blood products or transfusions overseas or before 1985
6. occupational risk (sex worker)
7. sexual assault

6. Implications
- “what would you do if positive result?”
- disclosure (partner, occupation, insurance)
- social support
- ? health advisor
Hx: Breast History

1. Introduction
- consent
- name, age, occupation

2. Presenting Complaint
1. breast lump
- location
- onset, duration & cyclicity
- increase in size?
2. breast pain (mastalgia)
- socrates
- onset, duration & cyclicity
3. nipple discharge
- amount
- colour
- uni-/bilateral?, spontaneous?
+ nipple inversion, nipple tethering, skin changes
+ previous history?

3. Other History
- Medical History – previous breast disease
- Gynae History – menstrual (menarche, menopause, LMP & cycle length)
- Obs History – pregnancies, breastfeeding
- Drug History – COC, HRT
- Family History – breast Ca (ages)
- Social History – smoking, alcohol, illicit drugs
– accommodation, finances, social support

4. Finish
- “anything else you want to tell me that I haven’t asked about?”
- “anything worrying you?”
- *Triple Assessment (clinical examination, imaging, biopsy)
Ex: Breast Examination

Introduction
- Chaperone
- Consent
- Expose (undress from waist upwards)

1. Inspection
1. nipples – retraction, Paget’s disease of nipple
2. skin – congested veins, dimpling, peau d’orange skin
3. movement – nipple/lump tethering or asymmetrical contour changes
(raise & lower arm , then press against hips)

2. Palpation
1. Breast
- hand behind head
- systematic palpation (4 quadrants + tail i.e. upper/lower, inner/outer)
- squeeze nipple for discharge
2. Axillary Nodes
- lift & abduct arm (support & palpate with other hand)
- systematic palpation (apical, anterior, posterior, humeral)

3. Finish
- * palpate infraclavicular & supraclavicular nodes
- * auscultate lungs

Fibroadenoma = single painless, non-tender, soft, smooth lump

Fibrocystic Change = multiple/single tender lumps
Breast Cyst = single/multiple painful, tender, firm, smooth lump
Breast Carcinoma = single painless, non-tender, firm, irregular lump
+ nipple discharge, nipple retraction, tethering, peau d’orange
+ enlarged axillary nodes

Lump
1. position 4. consistency
2. size 5. tenderness
3. shape 6. fixation