Call Girl Surat Madhuri 7001305949 Independent Escort Service Surat
History taking format for gyne
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 CHRONOLOGICAL 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, 3rd
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 1st
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): 1st
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 ( 1st
leopolds)
Lateral grip ( 2nd
leopolds)
First and second pelvic grip ( 3rd
and 4th
)
( 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 1st
stage of labor
P2+0 AT 3RD
day of peuperium after normal delivery with puerperal sepsis
P1+0 at 2nd
post op day of LSCS for fetal distress
P3+0 at 1st
day of forcep delivery for prolonged 2nd
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: 1st
trimester
2. Anomaly scan: 18-20 weeks
3. 3RD
scan at 38-40 weeks for fetal presentation, liqor volume (AFI), placental maturity grading,
estimated fetal weight
Medications during pregnancy
1. 1st
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 – 1ST
dose 2nd
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 3RD
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 2ND
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 1st
day, soft diet on 2nd
day and normal diet on 3rd
day
In abdominal surgeries including LSCS, dressing of wound done on 4th
day and discharge
if patient is stable
In VH cases, catheter clamped on 3rd
day, after 2nd
sensation of bladder filling, catheter
take out and patient discharged on 4th
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 PEURPERAL 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