OBGYN CLERKING & PRESENTATION

HISTORY TAKING AND EXAMINATIONDr MUSA MARENA

OBGYN

OBGYN

Crucial issue during history taking areRespect PrivacyConfidentiality

Information should flow in a Logical Chronological sequence in a paragraph format ( as in writing/telling

story).History taking should not be simply translating the patient’s

words into Medical English Language, but should get the clinician to Ask further questions for clarification.Form a provisional diagnosis that he/she would

Plan the examination Investigations Treatment accordingly 04/07/232 UTG OBGYN

GETTING READYIntroduce yourself with a friendly greeting

Give your name and status

Explain the purpose of your interview

Maintain good eye contact

Listen attentively

Facilitate verbally and non verbally communication

Ask for a background information about the patient, which includes

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PERSONAL AND DEMOGRAPHIC DATA

NameAgeSexOccupationGravidity & ParityFirst day of last (normal)

menstrual period LMP.Gestational AgeExpected day of Delivery

EDDMarital statusTribeRace

ResidenceNationalityReligionAddressLevel of educationReferral center; sometime

date and time of referralDate/time of

presentation/clerkingInformantReliability of information

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Systems of Terminology Gravidity: order of the current pregnancy (if pregnant now) Gravidity: is total number of present and previous pregnancies

Parity: outcome of previous pregnancies Parity: is the number of pregnancies resulting in a live birth (at whatever gestation)

together with all stillbirths plus the number of miscarriages, terminations and ectopic pregnancies. A multiple pregnancy is counted as one.

Delivery: >28weeks Term Delivery:>37weeks Preterm: <38weeks Miscarriage/Abortion: <28weeks Notations GDA written as GaPb+c GTPAL written as GaPbcde G=gravidity T=term deliveries P=preterm

deliveries A=abortions including ectopic pregnancies L=number of living children Gravida……., Para………. Para b+c (b=delivery c=miscarriage including ectopic preg) Para a,b,c,d (a=full term, b=preterm, c=miscarriages d=living children)

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5 UTG OBGYN

CASE EXAMPLES/Exercises

A woman who is not pregnant and has a term single live birth, one miscarriage and one termination =G3P1+2 or G3P1020

A woman who is pregnant with singleton pregnancy and has had two previous pregnancies resulting in a premature live birth and term stillbirth=G3P2+0 or G3P1101

A woman who has a singleton pregnancy and has had live twins at term and previous ectopic= G3P1+1 or G3P1012

A woman who is not pregnant but had a twin pregnancy resulting in live preterm births=G1P1+0 or G1P0102

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Gestational age

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Gestational age in weeks can be calculated in two waysusing number of days from LMP to Date of seeing the patient divided by

sevenExample if a client has her LMP of 12th august 2010 and she

is seen or clerk 15th march 2011 then her gestational age is20+30+31+30+31+31+28+15=216/7=30weeks 6days

August 11th-31st=20days =2W6D

September 1st-30th= 30days=4W2D

October 1st-31st=31days =4W3D

November 1st-30th=30days =4W2D

December1st-31st= 31days =4W3D

January 1st-31st=31days =4W3D

February 1st-28th=28days =4W0D

March 1st-15th=15days =2W1D

Total =30W6D

Using 40ks as references, subtract number of weeks between date you seeing the patient and the EDD from 40weeks

In previous example LMP 12th August 2010 hence EDD will be 19th may 2011 and date of consultation is 15th march 2011

o March 19th-31=12days=1W5Do April 1st-30th =30days=4W2Do May 1st-19th =19days=2W5Do Total =8W5Do Gestational age=40W0D-8W5D=31W2D

CALCULTION OF EXPECTED DAY OF DELIVERY

Using Nagaele ruleAssumptions made

28 day cycleOvulation occurs 14days before start of next menses

Two methods:Add 7days and 9months to the date of the 1st day of last menstrual

periodAdd 7days, subtract 3months and add 1year to the date of the 1st day

of last menstrual periodCycles longer than 28days, add the difference to the calculated

EDDCycles less than 28days subtract the difference from the

calculated EDD 04/07/239UTG OBGYN

Presenting Complaint

SymptomsMain complaints in order of occurrence; 1st symptom(s)

written or reported firstIn the patients own wordsTwo ways

Duration of the complaints (duration of symptom)Time of onset of symptom to time of patient presentation.

(duration prior to presentation)

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History of Presenting Complaint Elicit the evolution of the disease Progression of symptoms Appearances of new symptoms including treatments obtained and Response to treatment Spontaneous remissions and exacerbations and other related phenomena

Onset: acute or insidious Time and duration Character Volume , colour and consistency (fluids/liquids) location Progression Relieving Aggravating Associated factors

Onset, location, course, severity, duration What increase/decrease the symptoms Associated symptoms Others symptoms to prove or disprove provisional diagnosis Investigations done(date, place and results) Treatment received both traditional and orthodox (details & response) Any complications Direct questioning of related symptoms and signs


Index Pregnancy A chronological and concise account of the events in present pregnancy: is best

obtained by enquiring about her pregnancy in the first, second and third trimester. If she was in postnatal period details of labour and delivery are relevant Planned pregnancy including any Assisted Reproduction Technology in cases of

infertility Supported by partner/spouse (welcome by the couple) Day of ovulation, Fertilization, conception. {assisted conception), ‘quickening’ Illness and complications during this pregnancy Antenatal care

When booking/registration Number and frequency of visits Type of care History and type examination done Investigation done and results

Haematology urine Screening for infections and genetic anomalies' Imaging

Immunization and medications (type and when received)Elicit likely exposure to hazard/teratogens including medications


Past ObstetricsDate/years ago of

confinement in chronological order

Antenatal illness, care and complications

Maturity (preterm/term)Onset of labour

(spontaneous/induced)Place & Mode of deliveryoutcomeBaby’s sexBaby’s birth weightResuscitations, PPH etc

Postnatal complicationsNeonatal outcomeMode of feedingType and duration of infant

feedingHealth status age of the child

presently.


Gynaecological History Age at menarche LMP (was it conform to the usual in terms

of timing, volume, and appearance) Previous menses

When Cycle length Duration of menses Sure Reliable Symptoms: premenstrual tension,

dysmenorrhoea, menorrhagia, intermenstrual, postcoital bleeding etc

Previous Menstrual Period PMP Pap’s Smear: Last Smear

when, Where results Awareness and compliance on follow up HPV vacinations

Contraceptives/birth Control Methods: current method, what, when started,

satisfaction and any side effects. Previous methods: what, when and why

stopped Sexual Transmitted Infections and treatments Sexual History:

Coitarche and number of partners since coitarche

orientation, frequency Satisfaction Problems (dyspareuna, premature

ejaculation, impotence) Hx of Infertility Douching Abortions including ectopic pregnancies

(when, gestational age and mode of termination)

Gynae Operations: cone biopsy, cerclage, endometrial ablation etc

Regular breast examination (self or health worker)


Medical history Some medical conditions may have impact on the course of the pregnancy or

the pregnancy may have an impact on the medical condition examples HPT, DM, Sickle cell, heart dx, liver dx, renal dx, thyroid dx, HIV etc

Previous and Present Significant Illness not related to symptoms

Medical: mostly chronic illness e.g. diabetes, hypertension, asthma, tuberculosis, sickle cell and other genetic diseases, renal dx, liver dx, thyroid dx, psychiatric disorders, HIV etc

Previous Surgical & Anesthesia Experiences

Previous Hospital Admissions Previous hx of blood transfusion

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Drug HxMedications taking before onset of or not related this illness both

orthodox and traditonal medicines (esp those ingested)

Type, dose, duration and for what

Transfusions when and for what


Allergies

To medications

To food

others


Family Hx

Family Pedigree and health of members

Patient’s position in the family, type of family, number of members in the family.

Similar conditions as to patients complaints.

Diseases afflicting family members (familial disease, genetic diseases, congenital malformations, fetal anomalies or inborn errors of metabolism, malignancy, infections, infertility).

Multiple pregnancies.


Social HxMarital status, duration of relationship and spouse support.Occupation of coupleTobacco intake, alcohol intake and drug abuse (type, quantity

per day and duration of intake)Family incomeMeans of paying for medical care including insuranceHousingNumber of occupants in the roomHousing environment ( sanitation, feeding and food preparation

and storage, waste disposal, bed nets, water availability)


Systemic Review

Direct questioningNervous: headache, dizziness, blurred vision, fever, convulsion,

CVS: orthopnae, palpitation, leg swelling paroxysmal nocturnal dyspnaoe, exertional dyspnaoe

Respiratory: cough, dyspnoae tachypnae, chest pain, sputum, anosmia

Digestive: vomiting, dysphagia, odnyphagia, abdominal pain, diarrhoea, jaundice, haematochezia, melenae,

Urinary: incontinence, dysuria, frequency, urgency, precipitancy, retention, haematuria, loin pain

Reproductive: bleeding PV relationship to menses (menorrhagia, dymenorrhoea, metrorrhagia, oligomenoorhea and polymenorrhea) and sex

(postcoital bleeding), dysmenorrhea, abnormal vaginal discharge, vulva ulcers, papules or pustules, sexual dysfunction (dyspareunia/apareunia, frigidity, premature orgasm, nyphomania), rare sexual deversion (homo, bi or transexuality), infertility

Musculoskeletal: joint pain, joint stiffness, joint swelling, muscle and bone deformity , pain or atrophy


EXAMINATION

INSPECTION (I)PALPATION(P)PERCUSSION(P)AUSCULTATION(P)


GENERAL EXAMINATIONBuilt: obese, average or thinStriking feature (most obvious thing about the patient upon first

seeing her)Nutritional status: adequate or poorMental status and conscious levelLevels of Pallor, cyanoses, jaundice, pedal or sacral oedema, and

palpable peripheral lymphadenopathyMeasurements (anthropometry)

Weight, height, body mass index (BMI), temperature

Sometimes: pulse, blood pressure, respiratory rate, SO2


HEAD & NECK

HeadNeckthyroid


CHEST

Breast: (IPPA) normal (nulliparous or parous breast fed) or abnormal (nipple, areola, lumps abnormal discharges)

Chest wall: (symmetry, deformities, lesions and scars expansion

Lungs: (palpation, percussion and auscultation)

Heart: precordiun activity, position of apex beat, auscultate four valves for the normal I and II heart sounds and murmurs with their radiation 04/07/2324 UTG OBGYN

ABDOMENContour, SymmetryStraie, scar, skin pigmentation, linear nigra, fetal

movements, prominent masses/veinsTenderness, consistency, contractions, fetal movementsLiver, spleen, bladder, hernia orifices, bladderUterus

using leopald Maneuvers 1st identify the upper limit of fundus and fetal pole occupying the

fundus Fundal Height: determine with ulna border of left hand Measurement symphysis-fundal height after 20weeks because uterus

rises at a rate of 1cm every week after twentieth week using land marks Superior border of symphysis Pubis 12wks Distance between symphysis and umbilicus is divided into 3 equal

parts. Lower 3rd is reach at 16wks, 2/3rd is reach at 20wks Umbilicus24wks Distance between umbilicus and xiphisternum is divided into 3 equal

parts. Lower 3rd is reach at 28wks, 2/3rd is reach at 32wks Xisphisternum is reach 36wks Thereafter uterus descend and at 40ks fundus occupies the height at

32wks04/07/2325 UTG OBGYN

OBSTETRIC PALPATION

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Fundal Grip: gently pressed of fundal area between the two hands in an attempt to determine which pole of fetus is occupying the fundal area

2nd manoeuvre Umbilical Grip: hands are gently slip along the side of the uterus to the umbilical. Steadying one hand to stabilized the uterus, the other hand is use to palpate the other side to identify the back as a smooth elongated firm mass round area and the limbs as small irregular shapes in an area which is relatively empty.

3rd manoeuvre Pelvic Grip: obstetrician then turn to face the patients feet and place his hands with fingers extended he gently presses downward on the lower part of uterus along its sides and from side to side attempting to recognise the presenting part. Unless its fixed in the pelvic it can be balloted from side to side between the fingers.

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If the presenting part cannot be easily identify bec it fixed in the pelvis, the fingers are slipped further downwards and inwards until they dip into the pelvis brim.

If the hand which is on the same side as the fetal back slips more deeply than the other into the pelvis it can be assumed that the head is well fixed.

Pawlik. Is not always necessary and unless performed gently may be painful. Facing the patient’s head the right hand spread widely and pressed

into the suprapubic area above the inguinal ligament. When the fingers and thumb are approximated the presenting part

can be felt between them and its mobility above the pelvic brim determine

VAGINAVulva & Perineum

Discharges, ulcers, papules and pustules, bleeding and blood stain, hair distributions and infestation.

shape and size of labia majora, minora, clitoris hood and prepuce (be aware of circumcision). Bartholin gland and duct

Vestibular Urethra orifice, paraurethra opening(skene glands), integrity of frenulum

and fourchette, presence and shape of hymen including vagina orifice and opening of bartholin duct

Sterile speculum examination: SSS vaginal wall appearance Cervix appearance with Os closed or open Fornix esp posterior whether its appears full and bulging Digital cervix Uterus Adnexals Direct rectal examination:DRE for rectal mucosa and pelvic organs


SUMMARYPertinent Information that helped you to arrive at a specific

diagnosis and differentials. Not more than three lines or sentence.

1st sentence: Demographic, Presenting Complaint and History of Presenting Complaint in one sentence

2nd sentence: Obst, gynae, PMHx, Drug Hx, FHx, and SHx in one sentence

3rd sentence: Examination finding in one sentence


Diagnosis

Base on your findings from the patient through Interview and Examination.

Most likely cause of the Complaints and Additional History with Physical Findings

Atleast three Differentials with Similar Presentations


INVESTIGATIONSWe investigate for three reasons to

Confirm Diagnosis and Exclude Differentials Know Baseline Values and Extent of the Disease Monitor the Treatment

Order of the request should follow the above criteria What disease does the patient have? How serious or severe is the disease? Is the treatment working?

Priority of request (investigations) will depends on Necessity Availability Cost

Includes Haematology Serology Biochemistry Microbiology Cytology and Histology Imaging 04/07/2331 UTG OBGYN

TREATMENTNon Medical (Advice) also may be expectant (observe progress

without intervention

MedicalMedicineSurgery


Follow up

WhenFrequencyReasonDeposition (to where the patient was discharge to)


SAMPLE./TEMPLATE

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28YO Housewife, G5P3+1, LMP 22 July 2010, EDD 29 April 2011, GA 29W0D, a

Christian, a Mandinka, a Gambian, resides at Brikama

with high school level of education referred from Brikama health Centre on 10/feb/11

at 0900hrs on accounts of High Blood Pressure. Was admitted on 10th February 2011. date of clerking 15th February 2011

Informant selfShe is reliableNote in some instances religion, tribe, nationality,

residence and education may be placed under social history

PRESENTING COMPLAINING

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Complains ofDizziness 1day prior to presentationBlurred vision12hrs prior

HISTORY OF PRESENTING COMPLAIN

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Was apparently well until a day ago when she began to experience a frontal headache. It was throbbing and doesn’t radiates, it’s aggravated by bending head forward and prevented her from doing her daily chaos. It’s relieved by taking paracetamol. It was not associated with fever, joint pain, cough, dysuria, or diarrheoa

About 12 hours later she realises that her vision was getting blurred and she couldn’t see certain objected at far. She also felt dizzy and has had realises that her upper abdomen begins to pain. The dizziness and blurred visions were not associated with difficulty in breathing, easy fatigue, chest pain or fatigue on exercise.

She decided to go to Brikama Health Centre for consultation. There she was interviewed and her blood pressure was taken. She was told it was very high and was given some medicine to put under her tongue and was given two injections on her thigh. She was then referred to Royal Victoria Teaching Hospital (RVTH)

She was again interviewed at RVTH, examined, her urine and blood samples were taken and she was given some intravenous injections. She was told that she would be admitted and adviced to have completely bed rest.

Ultrasound scan was done for her and she was inform that her baby is find but she needs close monitoring because her condition is serious but manageable.

Since admission she had be receiving regular oral medications and IV injections but the injections only lasted for only her admission day. Now her vision is normal, dizziness and upper abdominal pain has subsided. She is only experiencing slight headache.

On Direct questioningFetal movement +,Headache+ ‘ dizziness+ ,

palpitation+ , blurred vision+ , epigastric pain+ , abdominal pain- , bleeding PV-, difficulty in breathing-, easy fatiguability- , dysuria- , frequency-

INDEX PREGNANCY

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Pregnancy was planned, spontaneously conceived and support by her husband.

Had no problems and was not taking any medication or had no x-rays during early weeks of this pregnancy

Booked for antenatal care at 3mths gestation and has had four visits so far and which were on appointment.

At first visit, a brief history was taken, she was examined and her urine and blood samples were taken and was told all her results were normal

She had received one injection on her shoulder which I assumed was tetanus toxoid vaccine.

She was given some iron tablets to drink daily and during her last visit she was given three white tablets to drink at once which I assume is fansidar and given health educations.

Subsequent visits, she was examined and quizz about any problems she might have had experienced or is experiencing now and given advices on food, exercises including daily activities, taking only prescribed medications and health living.

OBSTETRICS HISTORY

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Has had three previous deliveries and one abortions (confinements/pregnancies)

First was 8yrs ago and booked for antenatal care at 3mth and subsequent visits were on appointments. Had high blood pressure during the pregnancy which was controlled with oral medications taking daily and she had spontaneous vertex delivery at 9mnths in hospital. Labour lasted for 18hrs and membranes were ruptured just before delivery. Resulted in twin delivery weighing 2.5kg and 2.6kg respectively and all are males. She had normal puerperium, babies were exclusively breast fed for 4mth and completely wean at 2yrs. They are in grade 3 and doing well.

Second was 5yrs ago and 3rd was 3yrs ago. Their pregnancy was uneventful, has had regular antenatal care and both deliveries were spontaneous vertex at term in a hospital and are male and female respectively. Labour lasted for 16hr and 18hrs respectfully with membranes ruptured just before delivery and their puerperiums were normal with exclusive breast feeding for 4mth and weaned completely at 2yrs. They are in grade 1 and nursery school respectfully and doing well.

She had a spontaneous one yr ago.

GYNAE HISTORY

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Menarche occurs at age of 12yrsHas regular monthly cycle of 28days with 4days of menstrual

blood flowIts not assoc with dysmenorrhea, menorrhagia intermenstrual

bleeding or post coital bleedingHas knowledge of contraceptive but never used one beforeHer last pap’s smear was 4yrs ago and it was normal but she

had not receive HPV vaccineCoitarche occurs at 20yrs with her present husband and he has

been her only partner since then. She never had abnormal vaginal discharge or sores and has never been treated for sexual transmitted disease

She has satisfactory heterosexual relationship with her spouse and has had no dyspareunia, she doesn’t douche. She regularly does self breast examinations and hasn’t felt any mass yet.

Has had one spontaneous abortion 5yrs ago at 4mths gestation which was completed through evacuation of the uterus.

PAST MEDICAL HISTORY

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Has no history of HPT, DM, asthma, sickle cell disease, chronic cough, heart disease or renal disease.

She had a HIV test at booking visit and was told its negative

Has never been admitted for any ailment nor has she ever under surgery or anesthesia

She has never been transfuse with blood before.

Drug History

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Apart from her routine antenatal iron and folic acids she has had not been taken any medication both orthodox and tradition in the past.

Allergy

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Has no know allergy to food, medicine or other substances

FAMILY HISTORY

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Is 3rd of 6 children from the mother in a polygamous marriage of three wives and 15 children

Father died of chronic cough 5yrs ago and mother is a known HPT and on medication.

One of her full sister and her paternal half had twins

The rest of the family are wellThere is no history of HPT, DM, Asthma,

heart disease or renal disease in the family.

SOCIAL HISTORY

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She is marry for 10yrs in a monogamous relationship. Her 3 children are alive and doing well in school.She doesn’t take tobacco in any form, drink alcohol or take

hard drugs.Husband is a high school teacher and smokes half pack of

cigarette a day and a social drinker but doesn’t take hard drugs.

They are a tenant in a 4 bedroom house with electricity and pipe water supply with a flush toilet. They seldomly use mosquito nets which is insecticide treated and have 3 basic meals a day

She doesn’t have health insurance and fund her medicare from the family’s income. Her husband gives her approx $2 a day for feeding and family upkeeping.

SYSTEMIC REVIEW

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Nervous system: slight headache, dizziness, blurred vision had subsided, no fever,

Cardiovascular system: no dyspnoea, othopnoea, exertional dyspnoea, or chest pain.

Respiratory system: no cough, no chest pain, no dyspnoea Digestive system: no vomiting, no dysphagia, no nausea,

abdominal pain subsided, good appetite, no diarrhoea, no constipation

Urinary system: no dysuira, no frequency, no hesitency, no incontinence, no polyuria no loin pain

Reproductive system: no sores, no vaginal discharge, no vaginal bleeding, no draining liquor, no dyspareunia, fetal movement present.

Musculoskeletal system: no joint pain no muscle pain no joint swelling or stiffness, slight back pain, intermittent abdominal pain main associated with fetal movements, has swelling of both feet.

EXAMINATION

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UPON EXAMINATION SHE IS Medium size well dressed and adequately nourish lady

sitting comfortably on the bedNot in any obvious distress, not pale, acyanosed,

anicteric, bilateral non tender pitting pedal odema up to ankles, no palpable peripheral lymphadenopathy, afebril to touch and hydration satisfactory

Weight 70kg, height 168cm, Body mass index 24.8kg/m2

(normal)Respiratory rate 15cycles/min, pulse 70beats/min

regular and full, blood pressure 150/100mmHgNormal head with well plaited hairs, slightly puffy face

with normal skin.Normal neck, with normal thyroid gland and no

distended vessels

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CHEST: Normal chest, with no scars or lesions or tenderness , symmetrical expanding, equal normal tactile and vocal fremitus. vesicular breath sounds and good air entry.

Breast: Normal parous (pendulous) breast with normal nipple and areola, non tender with no palpable mass or abnormal discharges

HEART: precodium quiet, Apex 4ICSMCL, I &II normal sounds and no murmurs heard

ABDOMEN: symmetrically enlarged, linear nigra extending from superior border symphysis pubis to about 3cm above the umbilicus, straie gravidarium diffuse distributed infra umbilically, visible fetal movements, no scars and normal hernia orifices

soft non tender with no guarding, liver, spleen and kidneys are not palpable. She has a abdominopelvic which I presume is the gravid uterus.

symphysiofundal height is 40cm which corresponds to 40weeks plus or minus 2wks which does not commensurate with her gestational age of 29weeks.

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Multiple Fetus poles felt one in cephalic and other breech presentation, longitudinal lie, head engagement 5/5 and ballotable, two fetal heart sounds heard with one above has rate of 120beats/min and the other below the umbilicus has a rate of 130beats/min and both are normal.

Urinalysis: pH6, Sugar –ve, Protein +3, nitrite –ve, blood +2

Bedside clotting time is 6mins

Summary

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YO HW G5P3+1 with GA 29wk, who was referred because of high blood pressure, presented 1day history of severe continuous throbbing frontal headache associated with dizziness, blurred vision and epigastric pain.

She has had twin deliveries and pregnancy induce hypertension in the past with family history of twin pregnancy and hypertension.

Examination reveals puff face with odema of both feet and a high blood pressure, fundal height larger than gestational age with double fetal parts and heart sounds and a proteinuria of +3 with bedside clotthing time of 6mins

Diagnosis

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ProblemsSymptoms of imminent eclampsiaHigh blood pressureTwin gestationPreterm pregnancy

DDX imminent eclampsia with preterm twin pregnancy

Differential Diagnosis Chronic Hypertension with Super Imposed Pre-eclampsiaHELLPRenal dx (Nephrotic Syndrome)

Investigations

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Pelvic Ultrasound Scan: To confirm twin pregnancy fetal number, gestational age, fetal viability, placental position

and maturity, liquor volumeComplete blood count: (exclude HELLP syndrome)

Haemoglobin level Hb, platelet counts, white blood cell counts WBC, red blood cell count RBC, mean corpuscle volume MCV, mean corpuscle haemoglobin MCH, mean copsuscle haemoglobin concentration, platelet count, clotting profile

Liver enzymes: (Exclude HELLP)Alanine transferase ALT, aspartate transaminase AST, lactate

dehydrogenase LDH.Liver function test: exclude HELLP)

Total serum bilirubin, conjugated serum bilirubin and unconjugated serum bilirubin

Renal function test: (exclude renal Disease)Urine analysis, culture and sensitiveUrea, creatinine, uric acid

24 hours protein (exclude renal disease)

Management

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MotherPrevent convulsions

MAG NESIUM SULPHATEControl blood pressure

IV HYDRALAZINE METHYL DOPA

Continue managemt post deliverfetal well being

Fetal lung maturationFetal heart monitoring

INTERMITTENT CONTINUOUS

CARDIOTOCOGRAPHYDelivery of fetus as soon as possible

GYN HISTORY TAKING29YO lawyer, P0+1, LMP 15 April 2011, Informant self and husbandReliableC/O unable to conceived for 3yrs

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Despite regular unprotected sexual intercourse of 3 times per week for 3years she is unable to conceive.

There is adequate vaginal penetration with intravaginal ejaculation during each sexual contact and has normal libido. There is no use of lubricant during sex and no douching after sex.

She has no male pattern hair growthon her legs, thighs, chest, beard or mustarche, no hoarseness of voice or recent weight gain. No acnes

She has no recent blurred visions, headaches or discharges from her breast

She has no heat or cold intolerances, no excessive appetite, easy fatigue or weight lost

She has no excessive thirst, no frequent large urination, or frequent urination at night. 04/07/23UTG OBGYN55

On Direct Questioning(ODQ)Headache- galactorrhea- ,visual

disturbance- ,normal smell+, heat intolerance-, polyuria-, polyphagia- , abnormal vaginal discharge- , dyspareunia-, consummation+, painful menses-

GYNAEMenarch occurred at 13yrsShe has regular menstrual cycle of 30days with 4days of menstraul blood

flow.She has no dysmen, menorrh, PCB or inter bleedingShe has a satisfactory sexual relationships with mild deep dyspareunia

and is heterosexual and coitarche occurs at18yrs. She had 3 lifetime partners.

She had abnormal vaginal discharge 5yrs ago around 2weeks after meeting her 2nd partner and this was treated. She used to douche regularly with soap water but has stopped about yr ago. She had her best examine by a doctor 6mhts ago and was inform its normal.

She had an induced abortion using both oral and vaginal medication then suction evacuation at around 3months gestation 7yrs ago at a private clinic.

She used loop for 5yrs prior to marriage. Her earlier methods were combination of rhythm, withdrawal and condom, foam or diaphram during fertile periods.

Her last pap’s smear was a year ago and its was normal she had completed her HPV vaccination 1yr ago.

04/07/23UTG OBGYN57

PAST MEDICAL HISTORYShe had no past history of diabetes,

hypertension, asthma, sickle cell, tuberculosis, thyroid disease.her last HIV test was 7yrs ago and its was negative.

She had no past history of intra-abdominal operation or other operations. She had never received blood tansfusion and had no severe illness requiring admission in hospital.

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DRUG HISTORYShe had not taken any orthodox, traditional

or herbal medicine. She is presently on multivitamine and folic acids

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FAMILY HISTORYShe 4th of 4 children with two brothers and one sister from a

monogamous marriage.There is no history of infertility in family, no history of

tuberculosis, chromosomal abnormality, HPT, DM, asthma in the family.

All family members are well.

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SOCIAL HISTORYShe is married for 3yrs in a monogamous marriage. The couple do

not take tobacco in any form nor do they drink alcohol. She does not take any illicit drugs too. She is a Muslim, wollof, Gambian and lives at pipeline. She has health insurance and her husband gives her approx $15/day as feeding and her upkeeping

Her spouse is 33yrs old doctor, he has had right herniorrhape 5yrs ago, both of his testis are in his scrotum with no other palpable mass, he has no history of orchitis, mumps, tuberculosis, thyroid disease, diabetes, hypertension or recurrent rhinitis. He doesn’t have warm bath top or wear tight under wear. He has no family history of infertility, chromosomal or genetic disease.

Their marriage has been consummated for 3yrs now and they have been living together all these 3yrs.

They live in 3 bedroom house, with flush toilet and pipe born water supply and electricity supply with an indoor kitchen.

04/07/23UTG OBGYN61

SYSTEMIC REVIEWNervous system: no headache, no dizziness, no blurred vision had

subsided, no fever,Cardiovascular system: no dyspnoea, othopnoea, exertional

dyspnoea, or chest pain, no heat intolerance, Respiratory system: no cough, no chest pain, no dyspnoea Digestive system: no vomiting, no dysphagia, no nausea,

abdominal pain subsided, good appetite, no diarrhoea, no constipation, no polyphagia, no polydypsia.

Urinary system: no dysuira, no frequency, no hesitency, no incontinence, no polyuria no loin pain,

Reproductive system: no sores, no vaginal discharge, no vaginal bleeding, no dyspareunia, no loss of libido, no galactorrhea

Musculoskeletal system: no joint pain no muscle pain no joint swelling or stiffness, slight back pain, intermittent abdominal pain main associated with fetal movements, has swelling of both feet.

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ExaminationWell dressed, adequately nourished average sized young

lady.Not in any obvious distress, not pale, acyanosed,

anicteric, no palpable peripheral lymphadenopathy, no pedal or sacral odema and afebrile to touch and hydration satisfactory.

GCS 15/15 resp rate 16cycles/min, pulse 80beats/min full and regular, blood pressure 110/70mmHg, temp 36.7oC

Normal thyroid that moves with glutition and no other palpable neck swelling,

Normal nulliparous breast with well form nipples and areola, no discharges from nipple and no palpable mass.

Normal symmetrical chest, no abnormal hair growth, no palpable mass or tenderness, vesicular breath sounds

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Quiet precodium, apex beat 4ICSMCL, no thrill or heaves 1st and 2nd heart sounds normal and no murmur heard

Symmetrical full abdomen which moves with respiration, umbilicus is inverted, no scars, straies, and normal female pubic hair pattern, no hernia. Abd is soft, non tender, LSK not palpable and no other palpable mass.

Circumcised (clitorectomy) scar, no discharges, normal labias, normal urethra meatus, normal fourchette , hymen discontinue with about 4 corincular mitrifomis, normal fossa navicularis, normal vaginal wall ruggae and cervix with no discharges and has nulliparous Os.

Normal size non pregnant anterior-verted uterus, no cervical motion or adnexal tenderness or adnexal mass

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Normal sense of smell through each nostrils,Visual acuity is 6/6 and normal visual fields elicited through confrontation, no colour blindness, normal retina

All other cranial nerves are normalNormal extremities including normal size

head jaws, face and hands.

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Examination of spouseAn adequately nourished well dress man average build

and not in any obvious distress.Not pale acyanosed, anicteric, no peripheral odema, no

palpable lymphadenopathyGCS 15/15, respiratory rate15cycles/min, pulse

80beats/min full and regular blood pressure 120/70mmHgNo baldness, normal thyroid and normal chest with

normal male breast and normal male hair distibution on chest and no tenderness or swelling, has normal tactil and vocal fremitus and resonant percussion notes with vesicular breath sounds

Precodium quiet, apex beat 5ICSMCL, I & II are normal and no murmurs

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Abdomen full moves with respiration, male pattern pubic and abd hair distribution, Right para-midline scar. Abd is soft non tender LSK not palpable and no other palpable mass, typanitic percussion and 3 bowel sounds in 1min.

Normal circumcised penis, no discharges ulcers, nodules or pustules and is about 8cm long in non erect position, urethra meatus is at the tip of the glans penis no epi- or hypospedias, no palpable cord with the urethra has normal scrotum with both testis inside and each about 4cm diameter with not other palpable masses, vas differens are paalpble connected to the testis and normal epididymis, no tenderness felt.

Penis was easily stimulated into harden and erection with no deformity seen

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Summary 29YO lawyer, P0+1 unable to conceive

for 3yrs despite regular unprotected sexShe has had abnormal vaginal disharge

and used to douche in the past. She had induced abortion with instrumentation and now mild deep dyspareunia. her spouse appears normal male

She has a normal female appearances with normal menstrual cycle.

ProblemsUnable to conceivePrevious abnormal vaginal discharge and

douchingPrevious induce abortion with instruementation

IMPRESSION: Secondary Infertility (tubal block)

DIFFERENTIALSPeritoneal AdhesionsAsherman Syndrome ( Endometrial Synechia)Azoospermia/ Oligozoospermia

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INVESTIGATIONspouse

Pelvic ultrasonography Hysterosalpingography Hormone profile

Follicular stimulating hormone Luteinizing hormone Thyroid stimulating hormone Serum prolactine Luteal phase progesterone

(21day) Androgen estrogen

Laparascopy and chromotubation Hysterosalpinsonography hysteroscopy Karyotype Computer tomography/magnetic

resonance imaging

Cervical smear Pap’s smear Complete blood count Fasting blood sugar Urinalysis microscopy, culture

and sensitivity

CouplePostcoital test

SpouseSemen analysis Hormone profileKaryotypeTesticular biopsyVasography 04/07/23UTG OBGYN70

OBGYN INTERNSHIPSURVIVAL

DR MUSA MARENADEPARTMENT OF OBGYN

RVTH

Admission Orders These vary a little from case to case, but the following are fairly general (format is ADC VAN DISMAL):

Admit: To the specific service or team

Diagnosis: List the diagnosis and the names of any associated surgeries or procedures

Condition: Such as Stable vs. Fair vs. Guarded

Vitals: Frequency

Activity: Ambulation, showering

Nursing: Foley catheter management parameters Prophylaxis for deep venous thrombosis Incentive spirometry protocols

Call orders: Vital sign parameters for notifying the team Urine output parameters

Diet: Oral intake management

IV FLUID: Rates are typically set at 125 cc per hour

Special: Drain management

Oxygen management

Meds: Pain medications Prophylactic orders, such as for sleep or nausea The patients' regular medications

Allergies:

Labs: Typically includes hemoglobin/hematocrit04/07/23UTG OBGYN72

Sample Admission to Labor and Delivery Note• Date & time• Identification: (includes age, gravidity, parity, estimated gestational age, and

reason for admission):• 26yo G3P1A1 @ 38W5D EGA presents with painful contractions since noon. Pt

reports good fetal movement, and denies rupture of membranes or vaginal bleeding.• LMP:• Estimated date of confinement (EDC):• Chief complaint:• History of present illness (includes Prenatal Care (PNC): Labs, including HIV, GBS,

GDM/HTN, # PNC visits, wt gain, s=d, etc.• Past history:

Obstetrics: List each pregnancy (NSVD, wt 4000 grams, complicated by gestational

diabetes and shoulder dystocia) Gynecology:

• PMH and PSH: Medications: PNV, FeSO4 Allergies: No Known Drug Allergies (NKDA) Social history: Ask about Tobacco/EtOH/Drugs

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Physical exam (focused): General and Vital signs Lungs Cardiovascular – (Many pregnant women have a grade 1-2/6 systolic ejection murmur Abdomen – Gravid, fundus non-tender (NT), fundal height (FH) 38cm, Leopold maneuvers: Fetus is vertex (VTX), estimated fetal weight (EFW) 3300 gm Sterile speculum examination if indicated to rule out spontaneous rupture of membranes (SROM) Sterile vaginal exam (SVE) = 4cm/80%/VTX/ –1 as per Dr. Smith/time Extremities – No Cyanosis, clubbing or edema (C/C/E), NT

Pertinent Labs: Ultrasound:

Date: 10 wks by crown-rump length (CRL) Date: 20 wks, no anomalies

Assessment: 26yo G3P1 at term, in labor fetal heart rate tracing (FHRT) reassuring Intrauterine pregnancy (IUP) at 39 weeks gestation FHRT – Baseline 140’s, accelerations present, no decelerations Contractions – q 4-5 min Any pertinent past medical or surgical history

Plan: Admit to L&D NPO except ice chips IV – D5LR at 125 cc/hr Continuous electronic fetal monitoring CBC, T&S, RPR Anticipate NSVD 04/07/23UTG OBGYN74

DELIVERY NOTE• On (delivery date, time), this (age, race) female under(epidural, pudendal,

local, no) anesthesia delivered a viable (male, female) infant weighing (weight) with APGAR scores of (0-10) and (0-10) at 1 and 5minutes.

• Delivery was via (SVD, LTCS, classical CS) to a sterile field. (Nuchal cord reduced) infant was (bulb, DeLee) suctioned at (perineum, delivery). Cord clamped and cut and infant handed to waiting (paediatrician, Nurse). (Cord blood send for analysis). (weight) (intact, fragmented, meconium stained) placenta with (2,3) vessel cord delivered (spontaneously, with manual extraction) at (time). (amount) of (carboprost, methylrgonovine, oxytocin) given. (uterus, cervix, vagina, rectum) explored and (midline episiotomy, nth degree laceration, uterus and abdominal incision) repaired in a normal fashion with (type) suture. EBL (amount). Patient send to RR in stable condition. Infant taken to NBN in stable condition. Dr (name) attending

• Note: SVD=spontaneous vaginal delivery, LTCS= low transverse C-section, CS= C-section, EBL= estimated blood loss, RR=recovery room, NBN=newborn nursery

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Sample Delivery Note

Date and time: Summary:

Normal spontaneous vertex delivery (NSVD) of a live male, 3000 gm and Apgars 9/9. Delivered left occiputo-anterior (LOA), no nuchal cord, light meconium. Nose and mouth bulb suctioned at perineum; body delivered without difficulty. Cord clamped and cut. Baby handed to nurse. Placenta delivered spontaneously, intact. Fundus firm, minimal bleeding. Placenta appears intact with 3 vessel cord. Perineum and vagina inspected – small 2nd degree perineal laceration repaired under local anesthesia with 2-0 and 3-0 chromic suture in the usual fashion. Estimated Blood Loss (EBL) 350cc. Hemostasis. Pt tolerated procedure well, recovering in Labour & Delivery Room (LDR). Infant to WBN

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PROGRESS NOTES• Uses the SOAP Mnemonics• SUBJECT S: patient comment or complains, nursing comments• OBJECTIVE O:

VITALS: blood pressure, pulse, respiratory rate, temps, weight, O2 sat

INS/OUTS: IV fluids, PO intake, emesis, urine, stool, drainsEXAM: physical findingsMED: pertinent routine or new medicationsINVEST: new lab or procedure results

• ASSESSMENT: A: assessment based on above data• PLAN P: Medication change, Lab Tests, Procedures,

Consults(other disciplines), Discharge04/07/2377 UTG OBGYN

POSTPARTUM NOTE• Subjective: Patient’s comments or complaints, nursing comments

CHECK pain control, breast tenderness, quality of vaginal bleeding, urination, flatus, bowel movement, lower extremity swelling, ambulation, breast or bottle feed, birth control type

• Objective: VITALS: blood pressure, pulse, respirations, temperature INS/OUTS: IV fluids, PO intake, emesis, urine, stool, drains EXAM: breath sounds, bowel sounds, fundal height/consistency, incision/episiotomy condition, lower extremity

oedema, Homan’s sign. MEDS: RhoGAM, pain med, iron, vitamins, laxative, contraceptive LAB: CBC, RH status

• Assessment: Assessment based on data above

• Plan: Medication change, lab tests, procedures, consults, discharge04/07/23UTG OBGYN78

Sample Postpartum Notes (Soap format)

• Date and Time:• Subjective: Ask every patient about:

Breastfeeding – are they breastfeeding/planning to? How is it going? Baby able to latch on? breast tenderness?

Contraceptive plan with relevant sexual history Lochia (vaginal bleeding) – Clots? How many pads? Pain – cramps/perineal pain/leg pain? Relief with medication? Do they need more pain meds? Urination/bowel movement- have they had urine, flatus or had bowl movement? Pain? Colour? Frequency?

• Objective:• Vital signs and note tachycardia, elevated or low BP, maximum and current temperature• Focused physical exam including

Heart Lungs Breasts: engorged? Nipples – skin intact? Abd: Soft? Location of the uterine fundus – below umbilicus? Firm? Tender? Perineum: Assess lochia (blood on pad, how old is pad?) Visually inspect perineum – Hematoma? Edema? Sutures intact? Extremities: Edema? Cords? Tender?

• Postpartum labs: Hemoglobin or hematocrit Assessment/Plan: PPD#_ S/P NSVD or Vacuum or Forceps (with 4th-degree laceration, with pre-eclampsia

s/p Magnesium Sulfate) General assessment – Afebrile, doing well, tolerating diet Contraception plans (must discuss before patient goes home) Vaccines – does pt need rubella vaccine prior to discharge? Breastfeeding? Problems? Encourage. Rhogam, if Rh-negative Discharge and follow-up plan Patients usually go home if uncomplicated 24-48 hours postpartum Follow-up appointment scheduled in 2-6 weeks postpartum 04/07/23UTG OBGYN79

OPERATION NOTE DATE AND TIME: SURGEONS: Attending, residents, students who scrubbed ANESTHESIA: General endotracheal (GETA), spinal, local, etc PRE-OPERATIVE DIAGNOSIS: POST OPERATIVE DIAGNOSIS: PROCEDURE: Surgery performed FINDINGS: Rupture right cornual ectopic pregnancy with dead fetus intraperitoneal about

20wks GA, haemoperitoneum, 4cm follicular cyst, etc COMPLICATIONS: Tear to colon which was repaired ESTIMATED BLOOD LOSS: Amount in cc FLUIDS: Amount and type (electrolyte, blood, etc, in cc or units) URINE: amount and colour at end of operation DRAINS: Type and location SPECIMENS: Type send to pathology (right fallopian tube and fetus with placenta) CONDITIONS: Stable, Fair, Guarded, extubated, etc DISPOSITION: transfer to recovery room, postpartum room, Surgical ICU, etc

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Sample Operation Note Date and Time: Pre-op Diagnosis: Symptomatic uterine fibroids or Pregnancy at term, failure to progress` Post op Diagnosis: Same Surgeon: Attending, Residents, students Anesthesia: GET (general endotracheal, others include spinal, LMA, IV sedation) Procedure: TAH/BSO or Cesarean Section Findings: Exam under anesthesia (EUA) and operative findings Complication: Tear to bladder which was repaired EBL: 300 cc Urine Output: 200 cc, clear at the end of procedure Fluids: 2,500 cc crystalloid (include blood or blood products here) Drains: If placed Specimen: Cervix/uterus, placenta and cord. Condition: Fair, Stable, Guarded, extubated Disposition: Recovery room, Surgical ICU, postpartum room, etc

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Sample Postoperative Cesarean Section Orders/NoteSample C/S Orders

Admit to Recovery Room, then postpartum floor Diagnosis: Status post (s/p) C/S for failure to progress (FTP) Condition: Stable, Fair, Guarded Vitals: Routine, q shift, q4hours Allergies: None Activity: Ambulate with assistance this PM, then up ad lib Nursing: Strict input and output (I&O), Foley to catheter drainage, call MD for

Temp > 38.4, pulse > 110, BP < 90/60 or > 140/90, encourage breastfeeding, pad count, dressing checks, and Ted’s leg stockings until ambulating

Diet: Regular as tolerated; some hospitals only allow ice chips or clear liquids, semi solids IV: Lactated ringers (LR) or D5LR at 125 cc/hr, with 20 units of Pitocin x 1-2 Liters Labs: CBC in AM Medications:

Morphine sulfate PCA (patient controlled analgesia) per protocol (1 mg per dose with 10 minute lockout, not to exceed 20 mg/4 hours)

Percocet 1-2 tabs PO q 4-6 hours prn pain, when tolerating PO well Vistaril 25 mg IM or PO q 6 hours prn nausea Ibuprofen 800 mg PO q 8 hours prn pain, when tolerating PO well Prophylactic antibiotics if indicated Thromboprohylaxis for high-risk patients Rhogam, if Rh-negative 04/07/23UTG OBGYN82

Sample post operation (C/S) Note

Date and Time: Day #1 (Post-op day POD#1) Subjective: Ask patient about:

Pain – relieved with medication? Nausea/vomiting Passing flatus (rare this early post-op), stool

Objective: Vital signs and note tachycardia, elevated or low BP, maximum and current

temperature Input and output Focused physical exam including

Heart Lungs Breasts: engorged? Nipples – Is skin intact? Incision: Clean and dry? sutures intact? odema? haematoma? Abd: Soft? Location of the uterine fundus – below umbilicus? Firm? Tender? Perineum: Assess lochia (blood on pad, how old is pad? Frequency of

changing?) Visually inspect perineum – Hematoma? Edema? Sutures intact? Extremities: Edema? Cords? Tender?

Postpartum labs: Hemoglobin or hematocrit Fluids ins/outs; 04/07/23UTG OBGYN83

Assessment/Plan: POD#1 status post (S/P) C/S or repeat C/S (indication for the C/S) Afebrile, tolerating pain with medication, oral intake, adequate urine output (>30cc/hr) Routine post-op care Discharge Foley Discharge PCA or IV pain medications and PO pain Meds when tolerating PO Out of bed (OOB) Advance diet as tolerated Discharge IV when tolerating PO Check hematocrit or CBC

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OBGYN CLERKING & PRESENTATION

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