History taking format for gyne

history format for obs gyne cases and basic protocol for kist medical college in gyne obs

1. HISTORY TAKING FORMAT FOR GYNE/OBS


Patient’s particulars:
Patient No
Name Age Address
Marital status Occupation
Education Socioeconomic statues
Religion Date and time of admission (for in patients)


CHIEF COMPLAINS AND DURATION (IN CHRONOLOG ICAL ORDER)
1.
2.
3.
4.

HISTORY OF PRESENTING ILLNESS (HOPI)
Elaboration of each chief complaints in detail to reach a provisional diagnosis)
Obstetric history (History of previous pregnancies)
 Married for ………..duration/ age at marriage
 Gravid, parity, abortions (spontaneous/induced, duration of pregnancy, any complications, living
issue, year of last delivery
 Indication in cases of previous instrumental or operative delivery
 Significant antenatal problem, 3
rd
stage/ puerperal complications in previous deliveries
 Year and place of previous deliveries, sex of baby, live or still birth (fresh/macerated/wt of baby,
living or not, if neonatal death then  cause of death; congenital malformation
Year of marriage, gravid, para, abortion, living issue
No. Year ANC attendance/
pregnancy
complication
Period of
gestation
Type of
delivery/
abortion
Complications
in puerperium
Baby details:
Wt, sex,
Alive/SB/NND



Age of last child birth/ year of last pregnancy

2. MENSTRUAL HISTORY :
 Age of menarche (k): …….years
 Duration of flow …..days/ length of cycle (from first day of one cycle to 1
st
day of next cycle)
…..days ± ……days
 Regular/ irregular (range of shortes  longest cycle)
 Amount of flow, any passage of clots, no of soaked pads/day  fully soaked or not)
 Dysmenorrheal? Severity/duration
 Intermenstrual bleeding
 Post coital bleeding
 Last menstrual perid (LMP): 1
st
day of last normal menstrual period
 If menopausal  ask about duration/age of menopause and post menopausal bleeding

CONTRACEPTIVE HISTORY
 Type of contraception, duration, cause of discontinuation (if discontinued), date of
discontinuation, date of last dose if using depo provera
 Duration between last child and current pregnancy

PAST HISTORY
 Any medical or surgical history (Hx of TB, DM, HTN, epilepsy, endocrinal disorders, blood
transfusion, cardiac disease/ any surgical interventions in the past)
 History of STDs, recurrent PID

FAMILY HISTORY:
 Only primary relatives
 TB/DM/HTN/ female genital tract malignancies
 In Antenatal cases: multiple pregnancies, congenital anomalies (sp. Downs syndrome)

PERSONAL HISTORY
 Smoking (duration and no of cigarettes per day); alcohol intake; allergy, etc

TREATMENT HISTORY
 Any treatment done for present illness or any medication which the patient is taking regularly

3. SPECIAL POINTS TO CONSIDER IN HISTORY TAKING OF COMMON OBS/GYNE
PROBLEMS:
For antenatal cases:
 Duration of cessation of menses in months,
 LMP, EDD
 Gestation age in weeks
 Fetal movements; date of perception and whether normal or not (>10 /day)
 ANC attendance ( place/regularity and starting)
 TT immunization (no of doses, week at injection)
 Taking iron/calcium or folic acid
 Deworming done or not
Any problems in each trimester e.g. severe vomiting, pain abdomen, fever, urinary problems, vaginal
bleeding or abnormal discharge, severe headache, swelling/ any conditions requiring hospital admission
during this pregnancy should be noted

For labor cases (to be added in above history)
 Labor pain (duration in hours, continuous/intermittent, site, radiation, frequency, interval between
pains (in minutes), duration of pain( in seconds), severity {true vs false}
 Blood stained mucoid discharge PV (show), amount, duration
 Leaking (watery discharge PV) duration, color and smell

For postnatal cases (peurperium)
Chief complain
 Day of delivery
 Type of delivery: normal (completed 37 weeks, singleton, vertex presentation, spontaneous
vaginal delivery (ventouse/forcep) or cesarean section with indication. Other type of abnormal
delivery should be specified e.g. preterm, twin pregnancy, breech vaginal delivery, etc
 Pain lower abdomen after delivery (after pains)
 Blood stained discharge P/V (lochia): color, amount, smell
 Pain at wound (perineal/abdominal) site, swelling, discharge, etc
HOPI: She was admitted on ………….. at ……. With complaints of cessation of menses …… duration
and pain abdomen………. Hrs. Any intervention during labor e.g. augmentation (iv oxytocin drip),
artificial rupture of membrane,etc type, time outcome of delivery. Any third stage complications like post
partum hemorrhage, retained palcenta. Lactation started or not, any breast problem lie crack nipple,
engorgement or pain in breast. Urine passed/not after delivery, any bowel problems. Fever, pain in legs.
Any other problems after delivery. Condition of the baby
ANC Visit detail, any antenatal complications

4. FOR PAIN LOWER ABDOMEN:
 Duration, mode of onset, site, severity, radiation, referred pain, character aggravating/relieving
factor, relation to urinary/bowel symptoms, abnormal vaginal discharge, relation to menstrual
cycle, any history of amernorrhea, dyspareunia

FOR UTEROVAGINAL PROLAPSE
 Duration of something coming out per vagina, how it started, increasing or not, aggravated by
straining/ coughing, etc , reducible spontaneously on lying downs, has to be reduced manually or
not reducible
 Urinary problems’ leaking of urine on cough/laugh (stress incontinence), difficulty in passing
urine, inability to hold urine (urge incontinence), increased frequency or burning micturition,
retention, incomplete voiding, etc
 Bowel problems ( chronic constipation)
 History of chronic cough, smoking
 Smelly/blood stained discharge per vagina
 Previous treatment esp ring pessary of any surgical intervention for uv prolapsed
 In obstetric history: ask about prolonged/difficult labor, spacing between pregnancies, early
resumption of heavy work in peurperium + other risk factors for UVP

MASS IN ABDOMEN
 Duration, site of mass, onset
 Increasing or decreasing or same in size
 Pain, fever, discharge PV
 Association with menstrual problems: menorrhagia, metorrhagia, dysmennorhea
 Pressure symptoms: Urrinary retention; frequency; bowel problems, any change in bowel habit,
swelling of lower limbs, etc
 Loss of wt, appetite

VAGINAL DISCHARGE
 Durataion, type of discharge
 Occupation of both, possible multiple partners, contraceptive use
 Amount, color, smell, itching, pain lower abdomen, relation to menstrual cycle
 History of antibiotics intake, immunosupressants, OCPs
 Past history of vaginitis or cervicitis or PID
 Past and family history of DM

INABILITY TO CONCEIVE (SUBFERTILITY)
 Age and occupation of both partners

5.  Duration of marriage, duration/regularity of staying together
 Use of contraception
 Frequency of intercourse, awareness about fertility period, any problem in intercourse
 Any breast problems: galactorrhea
 Regularity of menstrual cycle
 Features suggestive of ovulation, regular cycle, premenstrual mastalgia, dysmenorrheal
 Any previous pregnancies: outcome, complications
 Any investigations or treatment done so far
 Past history of TB, recurrent PID, diabetes, thyroid disorder, pelvic surgeries
 Family history of TB, diabetes
 Drugs which may increase prolactin.. e.g phenothiazine, methyldopa, metoclopromide
 Smoking, alcohol abuse, drug abuse

MENSTRUAL PROBLEMS OR ABNORMAL PV BLEEDING:
 Duration, type of proble in terms of amount, duration of cycle, length, regularity (recent 6-12
months cycle pattern)
 Passage of clots, fleshy mass, any preceeding amenorrhea
 Associated pain/mass in lower abdomen
 Drug use esp hormones. Anticoagulants
 Contraceptive use; eg OCPs, depo provera, norplant, IUCD
 History of thyroid disorder, history suggestive of bleeding disorder, prolonged bleeding from cut
injuries, petechial rashes, bruises, gum bleeding etc
 Features associated with anemia: fatigue, palpitation, SOB, swelling, etc




FORMAT FOR PHYSICAL EXAMINATION
General examination:
 General condition: ill looking/fair, satisfactory, comfortable/distressed, built – average/thin/obese,
hydration
 Height, weight (must in ANC)
 Cardinal signs: Pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema, dehydration
{PICCLED}
 Vitals: Pulse; BP; respiratory rate; temperatyre
 Thyroid; breasts (symmetry, nipple, lump, tenderness)
 Cardiovascular system:
 Respiratory system

6. Abdomen:
 Inspection: ( contour, scars, pigmentation, linea niagra, stria gravidarum, stria albicans, venous
prominences, umbilicus, hernial orifices, movement with respiration, any visible mass)
 Palpation: tenderness, organomegaly, abnormal mass, raised temperature, guarding, rigidity, In
case of lump in abdomen: size, site, mobility, margin, surface, tenderness, lower border of mass
reached or not
 Percussion: (fluid/gas/mass/organs)
 Auscultation: Bowel sounds

Obstetrics (Antenatal Examination)
(Supine position with slightly flexed thighs and knees)
 Fundal height in realtion to gestation weeks ( symphysis fundal measurement with tape is
alternative method) —in cm ( after 20 weeks corresponds to WOG)
 Abdominal girth (in inches)—around the point of maximum buldge)
 Fundal grip ( 1
st
leopolds)
 Lateral grip ( 2
nd
leopolds)
 First and second pelvic grip ( 3
rd
and 4
th
)
 ( These examinations will tell the student about fundal height, fetal lie, attitude, position,
presentation and engagement of presenting part)
 Auscultation of fetal heart sound: rate/regularity


Labor cases (in addition to above)
 Uterine contractions (duration, frequency, intensity) should be noted

Postnatal cases:
 Height of uterus ( involution, weeks or cm)
 Uterus will be contracted or not, any tenderness
 In case of LSCS, site of wound, any soakage over dressing, bowel sounds


Pelvic examination:
In dorsal position, thighs and knees fully flexed and legs abducted ( patients should be examined with
empty bladder, only condition to examine patient while full bladder is when checking for urinary stress
incontinence)
 Inspection of external geitalia (pubic hair distribution, any laxity of introitus, any lesion, vaginal
discharge, bleeding, descent of vaginal wall or cervix
 Per speculum examination (inspection of cervix, lateral vaginal wall, any lesion, bleeding,
discharge or grwth\
 Bimanual examination of uterus (size, position, whether anterverted or retroverted, mobility and
tenderness, any abnormal mass/tenderness in lateral/anterior/posterior fornices), cervical motion
tenderness

7. In labor cases
 Pain abdomen: duration, site, nature intensity, frequency, progressive
 Blood stained discharge P/V (show)
 Watery discharge P/V: sudden gush or constant leakage, amount, duration
 Confirm gestation: LMP,EDD
 Fetal movements
 Dilation of cervical os: cm
 Effacement of cervix: % of shortening/thinning
 Membrane: present/absent
 Presenting part: vertex/breech/others
 Station of presenting part in realtion to ischial spine
 Position of presenting part (denominator in relation to maternal pelvis)
 Clinical assessment of pelvis: diagonal conjugate, interspinous diameter, curvature of sacrum,
suprapubic angle, transverse diameter of outlet, etc

In postnatal cases
 Lochia: color, amount, smell
 Any vulva/vaginal swelling or tenderness with bluish discoloration of skin
 Perineal wound/episiotomy site: stitches, swelling, discharge, etc
 Internal examination not done unless indicated in cases like subinvolution, puerperal sepsis,
suspected hematoma, retained pieces of placenta, post partum hemorrhage

After history and examination a provisional diagnosis to be reached. In obstetric cases, diagnosis should
be written completely including gravid, parity, gestational age, high risk conditions should be mentioned.
In case of post natal cases: postnatal cases day and type of delivery should be mentioned

Eg G3P1+1 AT 39 Weeks of pregenancy with previous LSCS in 1
st
stage of labor
P2+0 AT 3
RD
day of peuperium after normal delivery with puerperal sepsis
P1+0 at 2
nd
post op day of LSCS for fetal distress
P3+0 at 1
st
day of forcep delivery for prolonged 2
nd
stage of labor with PPH

8. PROTOCOL FOR ANTENATAL CHECKUP

Routine ANC investigations:
1. Hb%, Platelets
2. Blood grouping and Rh typing
3. VDRL (RPR)
4. HIV I and II
5. HBsAg
6. Random blood sugar
7. Urine routine


USG scan for ANC patients:
1. Dating scan: 1
st
trimester
2. Anomaly scan: 18-20 weeks
3. 3
RD
scan at 38-40 weeks for fetal presentation, liqor volume (AFI), placental maturity grading,
estimated fetal weight


Medications during pregnancy
1. 1
st
trimester: Tab FOLIC ACID – 5mg OD
Tab PERINORM 10 mg if needed
2. From 14 weeks onwards: Iron and calcium once daily, not to be taken at same time
3. Inj TT (0.5ml) im at 18 to 20 weeks – 1
ST
dose  2
nd
dose after 1 month
4. Deworming at the time of TT injection: Albendazole 400 mg single dose (at night)


Follow up in ANC:
1. Every 4 weeks upto 28 weeks
2. Every 2 weeks upto 36 weeks
3. Every week upto 41 weeks


Induction at 41 weeks ( after confirming the date) with:
 Cerviprime gel intracervical instillation at 2pm and 10pm or,
 Tab Misoprostol 24 μg at posterior fornix × 4 hourly after assessment × 3 doses
 Inj. Syntocinon drip at 6 am next morning depending on PV findings

9. Protocol for syntocinon:
2.5 units syntocinon in Inj. RL @ 10 drops/min, increase 1/2 hourly upto 40 drops/min depending on
uterine contractions and FHS {good contraction pattern ( 3 contraction in 10 min each lasting > 40secs)}
Do not give cerviprime, misoprostol or syntocinon in case of previous CS, malpresentation, grand
multipara, suspected CPD or fetal distress

PARTOGRAPH:
Once the patient is in active labor i.e. cervical os= 4cm dilated, partograph should be filled. Vaginal
examination should be done at 2 hr interval/SOS after that and each finding should be recoreded properly
to assess the progress of labor. After delivery, partograph should be completed filling all the details of
labor

Management of 3
RD
stage of labor:
 After delivery of bay, palpate abdomen to exclude multiple pregnancy
 IV oxytocin 10 units (IU)
 Control cord traction to deliver the placenta
 Massage the uterus to maintain contraction

Alternative uterotonics for management of PPH: Inj. Methergin 0.2mg im,
Tab Misoprostol 600μg/800 μg) oral/rectal
Inj. Carboprost 250 μg im should be available
In cases of unusual excessive bleeding or if CCT fails to deliver placenta within half hour, inform senior
on call immediately

In case of prolonged 2
ND
stage of labor: inform senior on call after half hour to avoid delay in
management

Post delivery order:
 Watch out for PPH and hematoma
 Record vitals each 6 hours
 Pericare and light BD
 Exclusive breast feeding
 Analgesics SOS
 Counselling for family planning
 Discharge the patient after 24 hours, if everything is ok
 Continue iron and calcium for 6 weeks and PNC follow up in OPD after 6 weeks in normal
delivery and 2 weeks in LSCS

10. Routine management of Post op patients:
 IV fluids and antibiotics and analgesics
 Inj. R/L + Inj DNS 6 pints over 24 hours
 Inj Pethidine 50mg + inj Phenargan 25 mg im 8 hourly
 Inj Diclofenac 75mg im SOS
 Inj Ranitidine 50 mg 8 hourly

ANTIBIOTICS
FOR LSCS and Laparotomy for ectopic pregnancy, ovarian cystectomy…
 Inj CEFTRIAXONE 1gm iv stat
 For TAH/VH
 Inj CIPROFLOXACIN 500mg IV BD
 Inj. METRON 500mg iv TDS
 Send post op Hb% next morning
 Iv drip omitted next morning after operation if patient stable
 Oral antibiotics to be continued for 7 days if needed
 Liquid diet on 1
st
day, soft diet on 2
nd
day and normal diet on 3
rd
day
 In abdominal surgeries including LSCS, dressing of wound done on 4
th
day and discharge
if patient is stable
 In VH cases, catheter clamped on 3
rd
day, after 2
nd
sensation of bladder filling, catheter
take out and patient discharged on 4
th
day after voiding of urine by herself
 All operated cases are followed up in OPD after 2 weeks or SOS

MANAGEMENT OF HYPEREMESIS GRAVIDARUM :
Investigations:
 Urine acetone DAILY till negative
 urine R/E
 Na/ K
 LFT
 Ultrasound scan for abdomen and pelvis to rule out multiple pregnancy, molar pregnancy and
surgical conditions like cholelithiasis or other hepatic diseases

Management:
 Nil per oral
 IV fluids:
o Total 6 pints fluid : II pint 10% dextrose, II pint RL and II pint DNS
o Inj B complex 1 ampule in I pint of 10% dextrose drip
o Inj. Perinorm 10 mg IV 8 hourly
o Inj. Ranitidine 50mg iv 8 hourly
 Once vomiting stops and urine acetone becomes negative patient is started with dry foods like
biscuits, bread, etc
 Decrease drip to 6-8 hrly

11.  Once tolerated then normal diet
 Ask patient about thirst, hunger, urine output during follow up history


OUTPATIENT TREATMENT OF CASE OF VAGINITIS
 Tinidazole 2gm single dose
 Fluconazole 150mg single dose
 Clotrimazole ointment local application TDS
 Clotrimazole 200mg vaginal pessary for 3 nights or 100mg vaginal pessary for 6 nights


OUTPATIENT TREATMENT OF CASE OF CERVICITIS
 Treatment same as vaginitis PLUS
 Azithromycin 500mg OD for 5 days
 Cefixime 400mg single dose

OUTPATIENT TREATMENT OF CASE OF PID
 Treatment for cervicitis PLUS
 Drotin (antispasmodic) 40mg tds for 5 days

IN-PATIENT TREATMENT OF CASE OF VAGINITIS
 Inj ceftriaxone 1gm iv 8 hourly till patient becomes afebrile and pain free for 24 hours and then
o Cefixime 200mg iv BD for 7 days

 Inj Metron 500mg iv 8 hourly till patient becomes afebrile and pain free for 24 hours and then
o Oral metron 400 mg 8 hourly for 7 days
PLUS
 Azithromycin 500mg


MANAGEMENT OF Rh negative pregnancy
Investigations to be sent during ANC:
1. Husband’s blood group and Rh type
2. Anti D titre
 For primi at 28 weeks
 For multi at any trimester

 Repeat Anti D titre after one month

 Plan for induction of labor at 40 weeks of gestation, if spontaneous labor doesn’t take place then:

12. o At the time of delivery of baby, send cord blood from placental side of the cord for
 Hb%
 Blood grouping and Rh typing
 Total and direct bilirubin
 Direct Coombs test
Injection anti-D-300 IU Intramuscular to be given to mother within 72 hours if direct coombs test is
negative and baby’s blood group is Rh positive


PREOPERATIVE INVESTIGATIONS FOR MAJOR SURGERIES:
1. Hb%, TC,DC Platelets
2. BT, CT
3. Blood grouping and Rh typing
4. Random blood sugar
5. Renal function test
6. HIV I & II
7. HBsAg
8. Urine r/e
9. Xray chest PA view
10. ECG
11. USG scan of Abdomen and Pelvis
12. Consult with anesthesiologist department night before surgery

PRE OP PREPARATION OF PATIENT:
 Nil per oral after 10pm the day before operation
 Soap water enema at 6 am on the operative day
 Clean the operative area
 Arrange II pints of cross matched blood


MANAGEMENT OF PRELABOUR RUPTURE OF MEMBRANE :
 Admit the patient, save pads, perform per speculum examination
 INVESTIGATIONS
o CBC, CRP, High vaginal swab C/S
 Antibiotics
o Erythromycin 500mg 6 hourly
 Syntocinon next morning at 6am


MANAGEMENT OF PRE-ECLAMPSIA
INVESTIGATIONS:
 Platelets

13.  Coagulation profile: BT, CT
 Uric acid
 RFT
 LFT
 Urine R/E
 24 hours urine albumin in case of severe pre eclampsia

Medications
 Antihypertensive if BP > 140/90 mm of Hg, in more than one occasion or >160/100mg on one
occasion start Capsule NIFEDIPINE 10mg orally 6-8 hourly
 MgSO4 as per national protocol in cases of sever pre-eclampsia or eclampsia

Plan for termination of pregnancy (induction or LSCS) if uncontrolled.


MANAGEMENT OF PEURPER AL PYREXIA:
Investigations:
CBC, High vaginal swab culture and sensivity, RFT, Blood culture, Urine routine and culture
Ultrasound scan to rule out retained POC

Medications:
 Inj ceftriaxone 1gm iv BD
 Inj. Metronidazole 500mg iv TDS
Parenteral antibiotics for minimum 3 days or when patient is afebrile 48 hours  switch to oral antibiotic
If fever persists or USG shows RPOC, plan for exploration