Академический Документы
Профессиональный Документы
Культура Документы
Richard Shaw
Menstrual History
Cycle
o Typical cycle length
o Regularity of cycles 21-35d
Bleeding
o 1st day of LMP and duration of menses
3-7d
o Flow
No. pads/tampons used in a day
4/5
Ever needed to double-up?
>80mL/period = heavy
Any flooding or clots?
Post-coital or intermenstrual
bleeding?
Menarche/Menopause ?ranges?
Associated Symptoms
o Primary vs Secondary Dysmenorrhoea
(timing)
o PMS
Obstetric History
Gravidity and Parity (= births >20/52)
o When were these pregnancies?
o Gestations (TermPremAbortLiving/GxPx systems)
o Fetal Outcomes
Ectopics, miscarriages (gestation
at miscarriage) , terminations,
normal birth
o Length of labour
Induced or spontaneous
o Delivery types and fetal presentations
o Sex and birthweight of babies
o Complications (ante, peri, postnatally)
Bleeding, infection, other?
Sexual History
Initial framing question - why and consent.
Are you sexually active?
o No have you ever been sexually active?
o Yes How long have you been sexually
active for? When did you last have a sexual
encounter with someone?
Practices
o Oral, Anal, Vaginal?
o Who does what? Insertive/Receptive,
Ejaculation?
o Do you have sex with men, women or both?
Partner
o Regular or casual?
type of relationship and duration
o Male or female partner? Similar symptoms?
Richard Shaw
Others
o UTIs, Vaginitis, Vulval Dermatitis, Fibroids
etc
Pap Smears
o Last pap smear results
Past Medical/Surgical History
Any surgeries? Gynaecological/Pelvic or otherwise?
Ever required a blood transfusion?
Weight gain/loss?, thyroid disease, epilepsy
DVT, ID-DM, Lung and Heart Disease, H/T,
Jaundice
Medications and Allergies
Drugs
o Prescribed drugs?
o Over the counter drugs?
o Herbs/supplements?
OCP/HRT
Allergies/Drug Allergies
o Penicillin? Latex?
Family History
Any conditions that run in the family?
o Endometriosis, PCOS,
cervical/ovarian/breast/colon cancer
o DM, DVT, H/T, Heart and Lung disease
o Twins in the family?
Timing of menopause in family members if
relevant
Osteoporosis, hirsutism etc as relevant
Psychosocial History
Drugs
o Smoking, Alcohol, Recreational Drugs
Home Supports
o Is there anyone at home to support you?
o Where do you live and what type of
accommodation is it?
o Childcare arrangements?
o Plans for breastfeeding?
Relationship
o Stability?
Education/Employment/Financial WHACS
ADLs and other activities
o Sleep, appetite, micturition, defecation
Exercise/Diet/Community Activities/Other
Richard Shaw
General Inspection
Skin quality
Palpation
Is there pain anywhere in your abdomen? Palpate this area last.
Light Palpation
Deep Palpation
Liver
Spleen
Put on gloves, and re-explain to patient what you intend to do.
Pelvis
Inspection
Blood discharge
Purulent discharge
Vaginitis, cervicitis,
endometritis, retained
tampon
Physiological discharge
Skin lesions
o Features of thrush or trichomoniasis
Leukoplakia
Redness
Swelling
Excoriation
o Ulceration
o Rashes
o Warts
o Scars
o Sinus openings
External genitalia
o Tenderness,
o Lumps and bumps
Cough Test
o Stress incontinence
o Cystocoele bulge from anterior
o Rectocoele blge from posterior
o Uterine Prolapse
o
o
Nabothian cysts
Size, Shape, Mobility
Tenderness
Tactile tenderness
Excitation tenderness
Dilatation/effacement
Fornices
o Anterior, posterior and lateral
Uterus
o Fingers in vagina are kept high up and rotated
to face upwards while left hand presses/rocks
above symphysis (perpendicular to linea alba)
o Fundal height
o Tenderness
Period Pain
Adenomyosis
o Position
Anteversion
Axial
Retroversion
Retroflexion
Anteflexion
Pregnancy
o
o
Richard Shaw
Adenomyosis
Submucous fibroids
Knobbly
Fibroids
Consistency
Soft pregnancy
Hard fibroids
Mobility
due to adhesions
Masses
Adnexa
o Turn fingers laterally to each side in turn and
bimanually palpate with left hand
o Attempt to feel for
Fallopian tubes
Broad ligament
Speculum Examination
Hold speculum with gun grip (handle facing up) and stand
on the right side of the patient - touch speculum to
fourchette (talk to patient the whole way through)
Vagina
Cervix
o Parity
Obstetric Examination
General Inspection
Distress of mother?
Obese
Fetal Movements
Inspection
o Striae
o Linea alba
o Scars
Palpation
o Fundal height (need to know gestation from Hx)
Richard Shaw
Squeezing of cord
Hypoxia
Speculum Examination
Vaginal Examination
Dilatation
Effacement
Position
o Occiput in relation to maternal pelvis
o Assists with finding best location to listen for
fetal heart sounds (over anterior shoulder)
Station
o Level of presenting part in relation to maternal
ischial spines
Bishops Score
o <7 not favourable
o > or = 7 favourable
Richard Shaw
Cardiovascular Examination
Respiratory Examination
Breast Examination
Skin Examination
o Oedema
o Spider angioma
o Striae
o Linea nigra
Mode of delivery:
o Caesarean
o Vaginal
o Instrumental
Passing urine?
Bowels/flatus?
Tenderness/redness/cracked nipples?
Educate on mastitis
Antenatal Card
Blood Group
o Does she need anti-D?
Rubella Immunity
o Does she need MMR?
Pap Smear
BP
Fundus
o Should be firm and below umbilicus
o Perineum if suturing
Richard Shaw