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This document provides guidance on clerking obstetrics cases and outlines the components of the clerking process. It describes taking a medical history including details of the current pregnancy, past medical/obstetric/gynecological history, menstrual history, and family history. It also describes performing a physical examination including inspection, vital signs, and abdominal/pelvic examinations to assess fetal position, presentation, engagement and estimate gestational age. The goal is to obtain all relevant information to determine the nature of the presenting problem and develop a treatment plan.
This document provides guidance on clerking obstetrics cases and outlines the components of the clerking process. It describes taking a medical history including details of the current pregnancy, past medical/obstetric/gynecological history, menstrual history, and family history. It also describes performing a physical examination including inspection, vital signs, and abdominal/pelvic examinations to assess fetal position, presentation, engagement and estimate gestational age. The goal is to obtain all relevant information to determine the nature of the presenting problem and develop a treatment plan.
This document provides guidance on clerking obstetrics cases and outlines the components of the clerking process. It describes taking a medical history including details of the current pregnancy, past medical/obstetric/gynecological history, menstrual history, and family history. It also describes performing a physical examination including inspection, vital signs, and abdominal/pelvic examinations to assess fetal position, presentation, engagement and estimate gestational age. The goal is to obtain all relevant information to determine the nature of the presenting problem and develop a treatment plan.
2. Premature Rupture of membrane (PPROM), Preterm rupture of membrane (PROM), spontaneous rupture of membrane (SROM) 3. Abdominal pain (Preterm contractions & Preterm labour , UTI, URTI) 4. GDM 5. HTN, Pre-eclampsia 6. Post date 7. Anencephaly COMPONENTS IN CLERKING PROCESS HISTORY 1.Pt details ( name,age,occupation,Gravida,LMP, EDD or rEDD, POA or POG) if history of +1; need to confirm either it is miscarriage,ectopic pregnancy or molar pregnancy. 2.Chief complaints 3.History of presenting illness Elaboration of complains rule out differential diagnoses, causes,risk Any previous admission assess current fetal wellbeing ( fetal movement, quickening) on any treatment? History of previous problem in pregnancy 4. History of current pregnancy Planned/unplanned pregnancy, days of missed period, any prior UPT done at home. Physical examination : height, weight, blood pressure First ultrasound to confirm the gestational age of fetus ( single or multiple fetus, any congenital anomalies) Booking antenatal checkup when and where?( blood test, Hb, blood grouping and rhesus typing) Urinalysis Supplement and tetanus toxoid injection 1st dose Any plan for OGTT and indications 2nd trimester ; fetal kick chart ( completed 10 kicks at what time) Follow up, uterus corresponds to fetal age Tetanus toxoid injection 2nd dose ( 4 weeks before EDD) Past medical and surgical history Any previous medical/surgical disorders needing hospitalisation 5.Past obstetrics history Age of first pregnancy, male/female term/preterm, born through SVD or c-section (indication) with fetal weight on when, where. Detailed history of any miscarriage ( type, any d&c done, admission) 6.Past gynaecological history Any pap smear was done( ujian pangkal Rahim) and results Use COCP and if used, which method, successfulness and reasons.
Any gynaecological problems or procedure done ( fibroid, rupture
of ovarian) 7.Menstrual history Age of attained menarchy How long of menses ( duration of heavy menses and number of soaked pads use) Any menorrhagia, dysmenorrhea ( PMS symptoms and any medication took for dysmenorrhea), intermenstrual bleed. 8.Family history Ask about age and any medical conditions suffering by parents No. of siblings Any DM,HTN,renal/heart/liver failure, blood disorder (thrombophilia, anemia, thalassemia), breast, cervical or gynaecological malignancies. 9.Socioeconomic history How long has been married ( fertility problems), age & occupation of patient and husband, smoking or alcohol taken, financial problems, own house or lives with family. PHYSICAL EXAMINATION General examination ( right side of patient) : Inspection : patient is lying down on the bed, comfortable, conscious and alert, not in respiratory distress, well build, hydration status, height and weight (BMI) Hand&palm : pink and warm, koilonychia, capillary refill time, schamroths, fluctuation test for clubbing, Haemodynamically : pulse rate, Blood pressure, temperature and respiratory rate. Eye : no anemia, no jaundice Neck ( sitting position) : cervical lymphadenopathy and thyroid swelling Auscultation for heart sound and breath sound ( CVS& Respi) ; any murmur or reduced heart sound Leg : swelling and pedal edema ABDOMINAL EXAMINATION : Inspection : abdomen moves with respiration, umbilicus flat and central, linea nigra seen, striae gravidarum&albican, any pfannenstial scar,laparoscopic,midline or any other surgical scar, no dilated veins and no fetal movement seen. Symphysio fundal height (SFH) : in cm Assess uterine size ( at which level) Palpation ( ask patient if any pain at the abdomen, if any do palpate from most away from pain) : Fell for any superficial and deep tenderness, any mass Leopold maneuver : fundal grip ( fell for fetal pole either hard or firm, lateral grip for lie and pelvic grip for presentation)
summary of palpation : there is single fetus, longitudinal lie, cephalic
presentation, fetal back at wich maternal side, engagement, liquor is adequate or not, and estimated fetal weight. If presence of contraction : feel for 10 minutes. Assess the intensity and duration. Auscultation : using pinard I would like to end my examination with speculum and vaginal examination.
History and Examination in Obstetrics and Gynaecology Obstetrics History - Detailed History and Examination For The Assessment of Mother and Fetus, Identify Risk Factors in Them and Plan Management
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