History Taking Flashcards
What additional information must be included in a gynaecological history compared to any other history?
- Sexual history
- Obstetric history
What should you not forget to ask about in a gynaecological history?
- Last menstrual period
- Cycle
- Contraception/ sexually active
- Last smear test
Give examples of specific gynaecological presenting complaints.
- Menorrhagia
- Prolapse
- Pelvic pain
- Early pregnancy bleeding
How can you judge how heavy a period is?
- How many times do you change your pad/tampon?
- Do you flood?
- What type of pad/tampon are you using?
- Why do you change your pad?
- Do you get up during the night to change your protection?
- Do you pass clots?
What may pelvic pain associated with shoulder tip pain suggest?
Ectopic pregnancy
What is involved in a gynaecological examination?
- General examination
- Abdominal examination
- PV examination
- Speculum
What is looked at on vaginal examination?
- Position of the uterus
- Size of the uterus
- Mobility of the uterus
- Adnexal masses
- Tenderness/cervical excitation
What is asked about in an obstetric history?
- Parity
- Gynaecological history
- POH
- FH for genetic history
- SH for other children
What does parity mean?
Number of pregnancies
How is parity documented?
Para A + B
(A amount of deliveries after 24 weeks and B amount of deliveries before 24 weeks including terminations and miscarriages)
What is included in the past obstetric history?
- All previous pregnancies and outcomes
- Date
- Type of delivery
- LB/SB
- Weight and sex of the baby
- Any problems encountered during pregnancy/delivery/postnatally
What is involved in the obstetric examination?
- General examination including BP
- Abdominal examination
- FH
- Urine
How is fundal height measured?
- Mother lies in semi-recumbent position with empty bladder
- Palpate the fundus with 2 hands
- Secure tape measurement down at top of fundus
- Measure to top of symphysis pubis
- Measure along longitudinal axis of measurement
How do you summarise your findings a pregnant abdomen?
- The abdomen is distended compatible with pregnancy
- The fundal height is X which is/is not in keeping with gestation
- The lie is longitudinal/oblique/transverse
- The presentation is cephalic/breech (if transverse lie then is back up/back down)
- Head is /5 palpable
- FH is heard, rate=
What does SRM stand for?
Spontaneous rupture of membranes
