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This is all about pregnancy.
Remember to ask about the pill every time in a history

Overview of O&G history

  • The focus of this part of the course is on pregnancy (building on content delivered in BGD‐A).
  • Pregnancy is characterized by a number of possible symptoms, with significant variation between individuals and also between trimesters.
  • These symptoms include:
    • Fatigue
**Mood variations
**Breast tenderness and enlargement
    • Nausea and vomiting
**Urinary frequency
**Fluid retention
**Backache
**Weight gain

You will be expected to be able to question a pregnant woman about her pregnancy including assessing the impact of the pregnancy and her concerns. It is important that you do not focus solely on medical symptoms but consider these in the context of the pregnancy and the woman’s concerns.
The history of the pregnancy should include:

  • The estimated duration of the pregnancy (date of last menstrual period or estimated dates based on 
ultrasound)
  • The development of any symptoms during the pregnancy including symptoms common to pregnancy.
  • Past pregnancies, both full term and non (miscarriages/ terminations).


There are no objectives specifically related to the examination of a pregnant woman. Phase 1 students will not be expected to palpate the abdomen of a pregnant woman to ascertain features of the pregnancy. 
You may be asked to conduct a physical examination in a pregnant woman to demonstrate your examination skills generally e.g. measuring BP, examination of the lungs etc.

Impacts of pregnancy

  • Fatigue
  • Fatness
  • Morning sickness/nausea
  • Back pain
  • Swelling (ankle)
  • Mood change
  • Not wanting to eat certain foods, cravings for some foods
  • Emotional impact
  • Daunting/excited
  • Weight gain
  • Diet adjustment (smoking, alcohol)
  • Frequency, [incontinence (post-parturition)]: increased blood volume, compressed bladder
  • Social support
  • Fears (older = Down syndrome, younger = feeling incapable)
  • Lack of experience
  • Financial burden
  • Career limitation
  • Positives: joy, opportunity, hope
  • Whole life change
  • Partner issues, relationship stress
  • Think about these in terms of both physical and psychosocial

Note that pregnant women are not really patients (pregnancy is a normal physiological process).

  • Picture of pregnancy: screaming women on a white bed in a white room, lots of pain
  • This is not the normal - e.g. home births (in Australia, it's medicalised/pathologised)

Menstrual history

  • Neonatal history lies between obstetric and paediatric

When to use it

  • Symptoms related to the menstrual cycle or gynaecological history
    • Menstrual issues and gynaecological problems (including amenorrhoea due to excessive exercise, menorrhagia - heavy bleeding at menstruation)
  • Hormonal problems (endocrinology; polycystic ovaries; menopause)
  • Ectopic pregnancy (abdominal pain)
  • Dyspareunia (pain on sex; sex problems)

What information to elicit?

  • Cycle information
    • Length (should be 28 days is median: 21-35 spread)
    • Regularity, pain (dysmenorrhoea), quantity of flow (menorrhagia = heavy flow)
      • Any other changes you notice about your cycle/bleeding (e.g. spotting)
      • Any IMB (intramenstrual bleeding)
    • Typical period lasts 5 days (broad range: 3-7 days). Note: may notate cycles as 3-7/21-35
      • How many pads/tampons they usually use and how many they're using now
      • How well used are these sanitary products (some women change them even if they're very slightly used)
    • Bloating, breast tenderness, stomach cramps
  • Menarche (when first got period)
  • Menopause - flushing/flashes (end of ovulation in life; women can present with post-menopausal bleeding (PMB) - often associated with tumours)
  • Emotional changes (mood swings, psychological upset)

Treat this as normal, not as something embarrassing. This can be difficult to do. Start with an open question (tell me about your period), then you can ask more specific questions if you're getting nowhere (e.g. "what is your flow like"). Remember that patients sometimes aren't comfortable about it even you have gotten to the point of being comfortable.

  • "Do people respond differently to you in your periods?" - (Ask about a third party)
    • It's their perspective - she'll know if she's normally bad tempered - it's about the changes she notices
    • You can't give people insight into their problems (e.g. obese people - either they see it as a problem or they don't; periods: they see their mood swings as a problem or they don't)

Normally change pads about once every 4-6 hours. Remember to ask "what is your period like" rather than "menstrual cycle" - don't use technical terms. Be the lay person. "Spotting" is a normal term.

  • Structure: start with "when did you get it", then how it progressed, and further on to
  • Common flaw: don't say "you don't have any… do you?". This shuts down positive responses - you want to ask "is there anything else that happens around the time of your cycle."
    • Don't want to signal to indicate "No I don't", but instead go for positive things.

Obstetric history

  • Not standalone medical history - included it in a full medical history
  • Obstetric and paediatric history grow out of the past medical history (shares some of that information in common)
  • Typical questions of a past medical history

Questions

  • Any pregnancies? (included in any female medical history)
  • Any conditions/serious illnesses/diseases current or past?
  • Any hospitalisations?
  • Any surgical/other procedures (e.g. outside of the hospital, skin cancer removal, cosmetic surgery, colonoscopies, gastroscopies). Hospitals account for a tiny proportion of the patients in the community (they are the sickest - there is a lot of health care that goes on outside the hospital).

All of this is only useful if you have dates and details. Pregnancies:

  • Dates and details
  • Remember that pregnancies include gravidity (G; all pregnancies) and parity (P; live births). E.g. G4P3 - a miscarriage/stillborn/abortion/termination (there is some terminology around this - we'll learn later)
    • This is also possibly a woman who is in her 4th pregnancy
    • G2P4 = two sets of twins or one singleton and one triplet -- more details need to be investigated here
  • How many children have you had?
  • How many pregnancies have you had?
  • Any conditions/problems during pregnancy? Cues include:
    • Gestational diabetes
    • Hypertension in pregnancy
  • To term?
  • Mode of delivery? (Normal vaginal delivery (NVD), Vaginal delivery with induction (with drugs), instrumentation (forceps, Ventouse/drain plunger), C-section (either emergency or elective)).
  • Post-natal issues (depression (PND), incontinence). Depression - ask "how have things been like for you? How have you been?". Coping. Don't ask about "coping" particularly, instead ask "how are things going?" "I can imagine that would have a big impact on you? How have you been going?"
  • Feeding (breastfeeding, bottle)
  • Problems post birth e.g. tearing (episiotomy)
  • Expect bleeding post parturition to last up to a couple of weeks
  • Psychosocial: a lot of problems about people having expectations that aren't fulfilled in the pregnancy

Very recent article (yesterday): IVF can cause problems because the injection of a sperm into an egg can bypass the normal screening mechanism of the body to reject sperm (normally there is protection against genetic problems).

Remember "how many children do you have?" is different to "how many children have you had?" is different to "how many pregnancies have you had?". This can be an emotional question for some women, who may have had miscarriages or still births. In the case they do get emotional and cry it is important to:

  • Acknowledge their emotions (eg. "I can imagine that must have been very tough for you")
  • Allow them time to compose themselves. Very often they will continue by themselves.
  • Offer box of tissues etc.

Scenario

Imagine that right now, you or your partner becomes pregnant. Don't think hypothetically, use your current circumstances to answer the following questions:

  1. What is the impact on you?
    • Shock, happiness, anxiety, scared?
    • Who would you tell? Family? Partner? Friends?
    • What would you do? Abortion? Adoption? Keep the baby? Does your partner agree with your decision? What will you do if there is a disagreement?
  2. How will family react?
    • Sympathetic? Angry? Take some blame? Loss of trust?
    • Are there any religious or cultural barriers that must be dealt with?
  3. How will friends/peers react?
    • Supportive? Stigma associated with unplanned pregnancies?
  4. How will it affect your career?
    • Will you have to drop out of uni? Can you manage to raise a child and do uni? Would you defer for one year?
    • How will you support the child financially? Do you have time to work a job?
    • What sort of living arrangements will you make? Who will be the major carer for the baby?

The point of this scenario is to understand the major concerns of the patient, so that you as a doctor can fulfill your role. This involves:

  • Making sure both the mother and father express their desires and wishes properly (not pressured by each other or family etc.)
  • Guidance with their possible options (abortion, adoption, etc.)
  • Counseling??

Measuring Blood Pressure

There are two techniques: Palpation and Auscultation.

Palpation

  • Not completely accurate
  • Only measures systolic blood pressure
  • However it is useful in measuring high BP
    • This is because hypertension is often asymptomatic and often when using auscultation we only measure for regular levels (and thus can miss an extremely high systolic pressure)

Method:

  • Ensure patient is sitting down, with arm rested on desk, bed etc.
  • Attach the blood cuff, with the artery marker on top of the brachial artery
    • The brachial artery can be located by palpating medial to the biceps tendon
  • Feel for radial pulse
  • Pump cuff until you can no longer feel the radial pulse
  • Release air slowly (2mmHg/sec) until you feel the radial pulse again.
  • This is roughly the systolic pressure

Auscultation

  • More accurate method
  • Measures both systolic and diastolic blood pressure

Method:

  • Ensure patient is sitting down, with arm rested on desk, bed etc.
  • Attach the blood cuff, with the artery marker on top of the brachial artery
    • The brachial artery can be located by palpating medial to the biceps tendon
  • Place the stethoscope on top of the brachil artery (both bell and diaphragm sides work)
  • Pump cuff to roughly 20mmHg higher than the systolic pressure measured by the palpation method
  • The systolic pressure is when you first hear the Korotkoff sounds (see table below)
  • The diastolic pressure is when you stop hearing Korotkoff sounds (see table below)
Korotkoff Sound Description
I Quiet. Sound of blood spurting through artery, as the systolic blood pressure overcomes cuff pressure.
II Loudest.
III Softer.
IV Softer.
V Loss of noises. This is where the cuff pressure drops below the diastolic blood pressure.

Statistics

  • These statistics are provided to help you understand your role as a doctor
  • Statistics are gathered from the following article: Skinner, S. and Hickey, M, (2003) Current Priorities for Adolescent Sexual and Reproductive Health MJA 179,(3), 158-161. http://www.mja.com.au/public/issues/179_03_040803/ski10035_fm.html
  • In Australia 1/4 year 10 students and 1/2 year 12 students are sexually active
  • 10% of those who are sexually active get pregnant

The point is that its important to educate our patients, especially teenagers who are just starting to become sexually active, to help reduce unplanned pregnancies.