Obstetrics Gynaecological History Taking.pptx

Physical Therapy Intervention:

- Therapeutic exercises to improve strength, flexibility, and range of motion
- Modalities such as heat, cold, electrical stimulation, and ultrasound to reduce pain and inflammation
- Manual therapy techniques such as massage, joint mobilization, and soft tissue mobilization to improve tissue extensibility and reduce scar tissue
- Functional training to improve mobility, balance, and coordination
- Education on proper body mechanics, posture, and movement techniques to prevent further injury

Outcome Measures:

- Range of motion (ROM) measurements
- Muscle strength tests (e.g., manual muscle testing, dynamometry)
- Pain intensity scales (e.g., visual analog scale, numeric rating scale)
- Functional assessment questionnaires (e.g., Functional Independence Measure, Disability Rating Scale)
- Balance and coordination tests (e.g., Berg Balance Scale, Timed Up and Go Test)
- Patient-reported outcomes (e.g., satisfaction, quality of life)

These outcome measures assess the effectiveness of physical therapy interventions in improving physical function, reducing pain and disability, and enhancing overall well-being.

1. OBSTETRICS & GYNAECOLOGICAL HISTORY TAKING

2. OBSTETRICS & GYNAECOLOGICAL HISTORY TAKING An obstetric history involves asking questions relevant to a patient's current and previous pregnancies. Some of the questions are highly personal and therefore good communication skills and a respectful manner are absolutely essential. Taking an obstetric history requires asking a lot of questions that are not part of the "standard" history taking format and therefore it's important to understand what information you are expected to gain. It's also worth noting that before 18 weeks gestation, most obstetric conditions are unlikely and therefore your history should focus more on the gynaecological aspect (e.g. abdominal pain at 8 weeks gestation could be an ectopic pregnancy). Introduce yourself (including your name and role) Confirm the patient's details (name and date of birth) Explain the need to take a history Gain consent Ensure the patient is currently comfortable

3. KEY PREGNANCY DETAILS It is useful to confirm the gestational age, gravidity and parity early on in the consultation, as this will assist you in determining which questions are most relevant and what conditions are most likely. Gestational age, gravidity and parity would also usually be included at the beginning of any documentation or presentation of the patient. Gravidity (G) is the number of times a woman has been pregnant, regardless of the outcome (e.g. G2). Parity (P) is the total number of times a woman has given birth to a child with a gestational age of 24 weeks or more, regardless of whether the child was born alive or not (still birth).

4. EXAMPLE OF GRAVIDITY AND PARITY CALCULATION A patient is currently 26 weeks pregnant and already has two other children of her own. She also reports having had a miscarriage at 10 weeks and a stillbirth at 28 weeks. G5 : The patient's gravidity is 5 because she has had 5 pregnancies in total, regardless of the outcome. P3 : The patient's parity would be 3 because she has had 3 pregnancies which resulted in the birth of a child with a gestational age of greater than 24 weeks (one of which was a stillbirth).

5. PRESENTING COMPLAINT It's important to use open questioning to elicit the patient's presenting complaint: "So, what's brought you in today?" or "Tell me about your symptoms" Allow the patient time to answer, trying not to interrupt or direct the conversation Facilitate the patient to expand on their presenting complaint if required: "Ok, so tell me more about that" "Can you explain what that pain was like?"

6. HISTORY OF PRESENTING COMPLAINT Once the patient has had time to communicate their presenting complaint, you should then begin to explore the issue with further open and closed questions. ONSET When did the symptom start? Was the onset acute or gradual? DURATION How long did the symptom last? (e.g. minutes, hours, days, weeks, months, years) SEVERITY How severe does the patient feel the symptom is? Is it impacting significantly on their day-to-day life?

7. COURSE Is the symptom worsening, improving, or continuing to fluctuate? PATTERN (Intermittent/continuous) Is the symptom always present or does it come and go? If intermittent, how frequent is the symptom? PRECIPITATING FACTORS Are there any obvious triggers for the symptom? RELIEVING FACTORS Does anything appear to improve the symptoms? ASSOCIATED FEATURES Are there other symptoms that appear associated (e.g. fever/malaise)? PREVIOUS EPISODES Has the patient experienced this symptom previously? When did they last experience the symptom?

8. PAIN The acronym SOCRATES provides a useful framework for asking about pain (e.g. abdominal pain) as shown below. SITE Where is the pain? ONSET When did it start? Was the onset sudden or gradual? CHARACTER Is the pain sharp or a dull ache? Is the pain intermittent or continuous? RADIATION Does the pain radiate anywhere?

9. ASSOCIATIONS Are there any other symptoms associated with the pain? TIME COURSE What is the overall time course of the pain? (e.g. worsening, improving, fluctuating) EXACERBATING OR RELIEVING FACTORS Does anything make the pain worse or better? SEVERITY On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you've ever experienced?

10. OBSTETRIC SYMPTOMS Once you have completed exploring the history of presenting complaint, you need to move on to more focused questioning relating to the symptoms that may be relevant to pregnancy. We have included a focused list of the key symptoms to ask about when taking an obstetric history, followed by some background information on each, should you want to know a little more. Key symptoms to ask about Nausea and vomiting (hyperemesis gravidarum) Reduced fetal movements (may be a sign of fetal distress) Vaginal bleeding (antepartum haemorrhage, placenta previa, cervical causes) Abdominal pain (urinary tract infection, placental abruption, constipation, pelvic girdle pain) Vaginal loss (abnormal vaginal discharge or spontaneous rupture of membranes) Headache/Visual disturbance/Epigastric pain (pre-eclampsia) Pruritis (obstetric cholestasis)

11. NAUSEA AND VOMITING Nausea and vomiting are very common in pregnancy but are usually mild and only require reassurance and advice. Nausea and vomiting in pregnancy usually begin between fourth and seventh weeks of gestation, peaks between the ninth and sixteenth weeks and resolves by around the 20th week of pregnancy. Persistent vomiting and severe nausea can progress to hyperemesis gravidarum. Hyperemesis gravidarum refers to persistent and severe vomiting leading to dehydration and electrolyte disturbance, weight loss and ketonuria.

12. REDUCED FETAL MOVEMENTS Women should start to feel fetal movements between 16 to 24 weeks gestation. Primigravida women will often not feel fetal movements until after 20 weeks gestation. A mother will know what is the "usual" amount of fetal movements she experiences and therefore if a reduction in fetal movements is reported, it should be taken very seriously. Reduced fetal movements are associated with adverse pregnancy outcomes, including stillbirth, fetal growth restriction, placental insufficiency, and congenital malformations. You should therefore always ask about fetal movements one the patient is of the appropriate, gestation to be able to feel them: "Have you noticed any change in the amount of baby's movement?"

13. VAGINAL BLEEDING Abnormal vaginal bleeding is an important symptom that can be relevant to a wide range of obstetric and gynecological diseases. It is important to ask about pain, associated trauma (including domestic violence), fever/malaise, recent ultrasound scan results (e.g. position of placenta), cervical screening history, sexual history and past medical history to help narrow the differential diagnosis. You should also ask about fatigue if anemia is suspected and symptoms of hypovolemic shock (e.g. pre-syncope/syncope) if large blood loss is suspected.

14. VAGINAL DISCHARGE All healthy women will have some degree of regular vaginal discharge, so it is important to distinguish between normal and abnormal vaginal discharge when taking an obstetric history. You should ask if the patient has noticed any changes to the following characteristics of their vaginal discharge: Volume Color (e.g. green, yellow or blood-stained would suggest infection) Consistency (e.g. thickened or watery) Smell (e.g. fish-like smell in bacterial vaginosis)

15. URINARY SYMPTOMS Urinary tract infections are common in pregnancy and need to be treated promptly. Untreated urinary tract infections in pregnancy have been associated with increased risk of fetal death developmental delay and cerebral palsy. Common symptoms of urinary tract infections include: Dysuria - pain when passing urine Frequency - increased frequency of passing urine Urgency - a sudden need to pass urine, with no earlier warning Fever

16. HEADACHE / VISUAL CHANGES / SWELLING Pre-eclampsia is a relatively common condition in pregnancy which is characterized by maternal hypertension, proteinuria, edema , fetal intrauterine growth restriction and premature birth. The condition can be life-threatening for the mother and the fetus . As a result, it is essential to ask about symptoms of pre-eclampsia as part of every patient review during pregnancy^ The key symptoms to ask about include: Headache (typically severe and frontal) Swelling of the hands, feet and face ( edema ) Pain in the upper part of the abdomen (epigastric tenderness) Visual disturbance (blurring of vision or flashing lights) Reduced fetal movements

17. OTHER RELEVANT SYMPTOMS Fever is important to ask about when considering infectious pathology (e.g. urinary tract infections, cervical infections, chorioamnionitis). Fatigue is a non-specific symptom, but its presence may indicate anemia or other systemic pathology. Weight loss is a symptom of hyperemesis gravidarum and -other significant conditions (e.g. malignancy, anorexia nervosa). Pruritis can occur in obstetric cholestasis.

18. CURRENT PREGNANCY GESTATION Clarify the current gestational age of the pregnancy (e g. 26 weeks and 5 days would be written as "26+5"). Accurate estimation of gestation and estimated date of delivery (EDD) is performed using an ultrasound scan to measure the crown-rump length. SCAN RESULTS : Women are offered an ultrasound scan to check for fetal anomalies between 18+0 and 20+6 weeks. You should ask about the results of the scan (or check the medical records if the patient is unsure). The key findings you should ask about include: Growth of the fetus - clarify if it was within normal limits for the current gestation Placental position - if embedded in the lower third of the uterine cavity there is an increased risk of placenta previa. Fetal anomalies - note any abnormalities identified SCREENING : There are several types of screening that women are offered during pregnancy. You should clarify if the patient has opted for s creening and if so, what the results were. Down's syndrome screening Rhesus status and the presence of any antibodies Hepatitis B, HIV and syphilis.

19. OTHER DETAILS OF THE PREGNANCY Singleton or multiple gestation Clarify if the patient took folic acid prior to conception and during the first trimester Planned mode of delivery (e.g. vaginal or Caesarian section) Medical illness during pregnancy (clarify what type of illness and if they are receiving any treatment

20. HISTORY IMMUNISATION HISTORY Check the patient is currently up to date with their vaccinations: Flu vaccination Whooping cough vaccination Hepatitis B vaccination (if at risk) MENTAL HEALTH HISTORY Pregnancy can have a significant impact on maternal mental health and therefore it is essential that patients are screened for symptoms suggestive of psychiatric illness (e.g. depression, bipolar; disorder, schizophrenia). Ask about previous mental health diagnoses and any current thoughts of self-harm and/or suicide relevant.

21. PREVIOUS OBSTETRIC HISTORY It is important to ask about a woman's previous obstetric history, as this can often help inform the assessment GRAVIDITY AND PARITY Gravidity is the number of times a woman has been pregnant, regardless of the outcome. Parity is the total number of pregnancies carried over the threshold of viability.

22. GYNECOLOGICAL HISTORY CERVICAL SCREENING Previously known as cervical smears Confirm the date of the last cervical screening test Confirm the result of the last cervical screening test Ask if the patient received any treatment if the cervical screening test was abnormal and check if follow up is in place PREVIOUS GYNECOLOGICAL DIAGNOSES AND TREATMENTS Sexually transmitted infections Endometriosis Bartholin's cyst Cervical ectropion Malignancy (e.g. cervical, endometrial, ovarian)

23. PAST MEDICAL HISTORY A patient's medical history is highly relevant, as some medical conditions can worsen during pregnancy and/or have implications for the developing fetus . Examples of medical conditions that are important to be aware of during pregnancy are shower below. DIABETES (TYPE 1 OR 2) Blood glucose control can deteriorate significantly during pregnancy resulting in poor maternal health and fetal complications (e.g. macrosomia) HYPOTHYROIDISM Untreated or undertreated hypothyroidism can result in congenital hypothyroidism with significant neurodevelopmental impact. EPILEPSY Seizures during pregnancy pose d risk to both the mother and fetus (e.g. miscarriage) Many anti-epileptic drugs are teratogenic.

24. PR E VIOUS VENOUS THROMBOEMBOLISM (VTE) Pregnancy is a pro-thrombotic state and therefore women who have previously had a venous thromboembolism are high risk for further VTEs . They may require prophylactic low molecular weight heparin to reduce their risk. BLOOD-BORNE VIRUSES HIV, Hepatitis B, Hepatitis C These pose a risk to the fetus during childbirth (vertical transmission) GENETIC DISEASE Cystic fibrosis, Sickle-cell disease, Thalassemia

25. SURGICAL HISTORY Previous surgical procedures such as: Abdominal or pelvic surgery - can result in adhesions that complicate Caesarian sections Caesarian section - increased risk of uterine rupture in subsequent pregnancies

26. DRUG HISTORY It is essential to gain an accurate overview of the medications the patient is currently and has previously taken during the pregnancy. The first trimester is when the fetus is most at risk of teratogenicity from drugs, as this is when organogenesis occurs. REGULAR MEDICATIONS Clarify the medications the patient has been taking since falling pregnant, noting which they are still taking and which they have now stopped. Some examples of drugs that are known to be teratogenic include: ACE inhibitors Sodium valproate Methotrexate Retinoids Trimethoprim

27. CONTRACEPTION Ask if the patient was using contraception prior to falling pregnant and if so, clarify what method of contraception was being used. Check the patient has stopped their contraception or had their contraceptive device removed (e.g. coil, implant).

28. MEDICATIONS FREQUENTLY USED DURING PREGNANCY Some medications are commonly used in pregnancy to both reduce the risk of fetal malformations and treat the symptoms of pregnancy. Some examples of medications commonly used in pregnancy include: Folic acid (400 u g) - recommended daily for the first trimester of pregnancy to reduce the risk of neural tube defects in the developing fetus Oral iron - frequently used in pregnancy to treat anemia Antiemetics - frequently used in pregnancy to manage nausea and vomiting (e.g. hyperemesis gravidarum) Antacids - frequently used to manage gastro- esophageal reflux symptoms during pregnancy Aspirin OVER THE COUNTER MEDICATIONS You should clarify if the patient is using any over the counter medications, as some of these have the potential to impact the pregnancy: Analgesics - Paracetamol, Ibuprofen, Codeine Herbal remedies

29. ALLERGIES It's essential to clarify any allergies the patient may have and document these clearly in the notes, ' including the type of allergic reaction the patient experienced. FAMILY HISTORY Taking a brief family history can help to further assess the risk of adverse outcomes to the mother and fetus during pregnancy. This can also help inform discussions with parents about the risk of their child having a specific genetic disease (e.g. cystic fibrosis). Some important areas to cover include: Inherited genetic conditions (e.g. cystic fibrosis, sickle-cell disease) Type 2 diabetes (first-degree relative) - increased risk of developing gestational diabetes Pre-eclampsia (maternal mother or sister) - increased risk of developing pre-eclampsia

30. SOCIAL HISTORY Understanding the social context of a patient is absolutely key to building a complete picture of their health. Social factors have a significant influence on a patient's pregnancy and it's therefore key that a comprehensive social history is obtained. SMOKING How many cigarettes a day? How long have they smoked for? Would they be interested in support from a stop smoking service? ALCOHOL How many units a week? Clarify the type, volume and strength of the alcohol Would they be interested in support from an alcohol cessation service?

31. RECREATIONAL DRUGS It is important to ask about recreational drug use, as these can potentially have significant consequences on the mother and developing fetus (e.g. cocaine use increases the risk of placental abruption). If recreational drug use is identified, patients can be offered input from drug cessation servicers. DIET AND WEIGHT Clarify if the patient is managing to eat a balanced diet whilst pregnant Ask about the patient's current weight - obesity significantly Increases the risk of venous thromboembolism, pre-eclampsia and gestational diabetes during pregnancy HOME SITUATION Who lives with the patient? Do they feel well supported? Are there other children at home? Is the patient independent or do they require assistance? How is the pregnancy impacting on their ability to carry out activities of daily living? If receiving care input, what level are they requiring?

32. OCCUPATION Ask about the patient's current or previous occupation Ask about plans for maternity leave DOMESTIC ABUSE It is important to ask all pregnant women if they are a victim of domestic abuse (in privacy) This provides an opportunity for women to seek help SYSTEMIC INQUIRY Systemic inquiry involves performing a brief screen for symptoms in other body systems. This may pick up on symptoms the patient failed to mention in the presenting complaint. Some of these symptoms may be relevant to the diagnosis (e.g. excessive vomiting in hyperemesis gravidarum).

33. Choosing which symptoms to ask about depends on the presenting complaint, however, a selection of potentially relevant systemic symptoms to an obstetric presentation are shown below. FEVER: Chorioamnionitis Urinary tract infection WEIGHT LOSS: Hyperemesis gravidarum Malignancy RESPIRATORY: Dyspnea (secondary to pulmonary embolism or anemia ) GASTROINTESTINAL : Abdominal pain (secondary to placental abruption) Vomiting (secondary to hyperemesis gravidarum)

34. URINARY : Frequency, dysuria and urgency (secondary to urinary tract infection) MUSCULOSKELETAL : Pelvic pain (secondary to symphysis pubis dysfunction) DERMATOLOGY: A pigmented line on abdomen ( linea nigra)