Dutta’s Bedside Clinics and Viva-Voce in Obstetrics and Gynecology.pdf

PATIENT PARTICULARS Name: Mrs...................... Age: ............... years Address: ...................................................................... Occupation: •  Religion: Educational status: •  Occupation of the husband: Duration of marriage: •  Socioeconomic status: Gravida: •  Date of admission: Parity: •  Date of examination: LMP................ EDD ................................... Period of gestation in weeks….........… Chief complaints: Pain abdomen/headache/vaginal bleeding/urinary problems are to be recorded, in order of priority or by chronological onset of events. Some patients may not have any complaints but have been admitted due to some significant observation like raised blood pressure (BP), or for investigations and planning mode of delivery as in a case with Rh-isoimmunization or pregnancy with prior cesarean delivery. History of present illness: Elaboration of the chief complaints as regard to their onset, duration, severity, use of medications, investigations, and progress, is to be made. History of present pregnancy: Important complications of different trimesters of the present pregnancy (if any) are to be recorded carefully. Number of antenatal visits (booking status), immunization status, intake of iron and folic acid are to be recorded. Any medication or radiation exposure in early pregnancy or medical/surgical events during pregnancy should be enquired and recorded. Woman’s perception of fetal movements may be mentioned. Obstetric history: Previous obstetric events are to be recorded chronologically. This is relevant in a multigravida. The obstetric history is summed up as gravida.........., para..........., miscarriage..........., MTP.......... and living issue........ Menstrual history: Menarche (age).......years, cycle 28–30 days, duration 3–4 days; amount of flow: (average/scanty), dysmenorrhea (if any). LMP..............EDD............. (Naegele’s formula); period of gestation............ weeks. History Taking and Clinical Examination CHAPTER 1 C :01:59 4 Bedside Clinics and Viva-Voce in Obstetrics and Gynecology Past medical history: Any relevant past medical illness (malaria and jaundice). Past surgical history: Previous surgery—general (appendicectomy) or gynecological (myomectomy). Family history: Hypertension, diabetes, hemoglobinopathy, twinning or congenital malformation or consanguineous marriage is to be enquired and recorded. Personal history: Contraceptive practice, smoking, chronic medications (corticosteroids), habit forming drugs are to be enquired. Sleep, appetite, bowel and bladder habits are to be mentioned. EXAMINATION � General survey � Mental status → Build → Nutrition → Height (Fig. 1.1) → Weight (Fig. 1.1) → Pallor → Jaundice → Cyanosis → Tongue, teeth, gum and tonsils → Neck veins → Neck glands → Thyroid → Breasts → Pulse → Blood pressure → Temperature → Respiratory rate → Edema legs To assess whether the individual is alert, conscious and co-operative. � Systemic examination ™ Examination of cardiovascular and respiratory system • Heart • Lungs ™ Musculoskeletal system ™ Examination of abdomen • Inspection • Palpation Any tenderness, liver, spleen (any organomegaly) ™ Obstetric examination: • Palpation • Obstetric grips • Percussion (not done) • Auscultation for fetal heart sound OBSTETRIC EXAMINATION Preliminaries: (a) Verbal consent from the patient should be taken, (b) presence of a female attendant, (c) prior bladder evacuation, (d) proper exposure of abdomen, (e) woman in dorsal posture with thighs and knees slightly flexed (Fig. 1.7), (f) the candidate is to stand on the right side of the patient. C :01:59 History Taking and Clinical Examination 5 EXAMINATION PROPER A. Inspection: Enlargement of the abdomen; uterine shape — ovoid (longitudinal/ transverse); contour of uterus — smooth or any fundal notching. Skin condition: Presence of linea nigra (Fig. 1.8), striae gravidarum, umbilicus (everted), presence of any scar mark, infection (scabies, if present) venous prominence, visible fetal movements, etc