history taking - Female Repro

Female Reproductive History Taking

This is sem 4  repro component
*female reproductive history taking is unique at some points – look at the bolded parts*

Things to ask;

1. demographics
2. chief complaint
3. history of chief complaint
4. menstrual history*
5. pregnancy history*
6. past medical history
7. social history

·         demographics

                                                               i.      Name

                                                             ii.      Age

                                                            iii.      Address

                                                           iv.      Religion

                                                             v.      Occupation

                                                           vi.      Marital status

                                                          vii.      Ethnicity

• Chief complaint – expect anything along the lines of…
• Abdominal cramps
• Contraception advice
• Trouble conscieving
• Vaginal itching / pain
• Menopausal symptoms
• Cancer checkup
• Amenorrhea
• Pain on lower back
• Infertility
• Irregular menstruation

Basically just ask what is the purpose of visit, and ask how long. It is the most important thing. You will need to change your question according to the chief complaint.

Menstrual history

• When was your first period?
• (if menopausal) – when was your last period?
• Most recent menstruation started on….. (date)
• Most recent menstruation ended on….
• Length of menstrual cycle? *in average – when short, when long.*
• How long does the menstruation last? (in days)
• How much is the menstrual blood loss?
• Any discomfort during menstruation?
• Any pre-menstrual symptoms?

Pregnancy history

• LMP - When was your first day of your last menstruation?
• How many times have you been pregnant? (gravida)
• *current pregnancy included*
• How many times have you given birth? (para)
• *twins / triplets are considered one para*
• Any miscarriages?
• Any complications during childbirth?
• How are the children?

You may be asked to calculate the EDD –Estimated Date of Delivary from the LMP

the expected date of delivery (EDD) is obtained by adding one year, subtracting three months, and adding seven days to the first day of a woman's last menstrual period (LMP).

Some extra points to remember –

fetal stage of prenatal development starts at the beginning of the 11th week in gestational age, which is the 9th week after fertilization.

Neonate - <28days after birth


the condition at which the pregnant mother feels nauseated for a prolonged period of time - is termed hyperemesis gravidarum

Pap smear

This examination is a component of sem4 Repro. system.

The not-so-important parts are highlighted in green.  Others are important.

Sequence of events

1.       GIEP (Very important)

2.       Wash hands

3.       Adjustment of the patient

4.       Glove-up

5.       Inspection of the pelvic area

6.       Cleaning of the pelvic area

7.       Insertion and fixation of the cusco’s bivalve speculum

8.       Inspection of the cervix

9.       Collection of cervical spear (pap smear) specimen

10.    Removing the speculum

11.    Thank, wash hands, and leave.

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Like the other CSU systems, the pap smear station will begin at GIEP - however, due to the nature of the exam, pap smear requires a through explanation and permission taking. Here’s a sample text (What I would say, If I were calm, had ample time and the facilitator is not Dr. FIA)

“Good morning, My name is ----------, a -- year medical student. How may I address you, madam?
Hello, Miss ------. Today I was instructed to do a pap-smear on you. This will involve you taking off your lower garment, and I would gently insert this instrument called a cusco’s speculum into your vagina, to collect some specimens for investigation. Please be ensured that this exam will be kept very private, and I will do my very best, to maintain your dignity. You will also be provided with a female chaperone throughout this exam.
Now, I don’t expect this to hurt, but please do tell me whenever it gets uncomfortable - I will stop immediately.
May I proceed? “

I know. That is mouthful… Basically, you will need to mention those key elements.

·         Greetings

·         Introduction

·         Get her name (and not her number)

·         Explanation

o    Which clothes she has to take off

o    What you’ll be inserting into her

o    What exactly is the purpose of this exam

o    Dignity and privacy

o    Cheperone

o    Reassurance that the patient may stop any time

·         Straight face (some people fail here. I am sorry for you)

Once you’re done with this, you can consider yourself 50% done with this station.

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Wash hands. Yeah.

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Positioning of patient

The patient would be in a particular position called lithotomy position. Mention this to the examiner.

“I will now instruct the patient to be in a lithotomy position. Miss ----, could you please lie down on your back and spread your legs, and keep your feet apart? I will finish this as soon as possible. Thank you”

Only expose her genital area. Cover the rest.

Also, adjust the light source behind you so that you can see things clearly.

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Glove up.

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Inspection of the external vaginal orifice.

·         Part the labia using your left hand

·         Inspect the presence of… (say it is “normal and present”)

o    Clitoris

o    Urethra

o    Vaginal opening

·         Bartholin’s glands (at the 5o’clock and 7o’clock direction of the vaginal opening

o    Discharge

o    Inflammation

o    Atrophy

o    Ulceration

·         Ask the lady to cough. Look out for (usually there won’t be. So comment “there is no…”

o    Prolapsed of vaginal wall

o    Involuntary urine leak

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Cleaning of the pelvic area

Now you clean the vagina basically. Use a tong, dispose the cotton after each wipe.

Explain before you do so.

“now, miss ----. I will clean your private area before I begin. Please bear with me”

1.       Clean the mons pubis

2.       Clean the labia majora (left)

3.       Clean the labia majora (right)

4.       Clean the labia minora (left)

5.       Clean the labia minora (right)

6.       Clean the vaginal opening

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Insertion of the cusco’s bivalve speculum into the vaginal orifice

Finally.

You will mention that this speculum is warmed and lubricated using warm water

(not lubricant gel, as this may interfere with the smear results)

The way you insert it, is important

1.       Hold the cusco’s speculum with your index finger above the valve, middle finger below.

2.       Ensure the speculum is closed.

3.       Turn the speculum 90 degrees, (like how a gangsta holds his gun)

4.       Warn the patient “now I will insert the speculum. Please relax…”

5.       Insert the speculum carefully slowly gently and with care.

6.       Slowly rotate as you go in, and also open the valve

7.       Visualize the cervix. You should see it… somewhere in there.

8.       Gently clamp the speculum onto the cervical Os.

9.       Fix the speculum using your left hand. (turn the screw)

10.    Now you’re done setting up the speculum.

11.    Note the cervix

a.        Erosion

b.       Polyp

c.        Malignancy

d.       Note if its nulliparous / multiparous

12.    Now take a cervical smear

a.        Ensure that the slide is labeled in pencil patient’s details and date

b.       Use an Ayre’s spatula (the one that looks like a dog-bone) to collect the cervical tissue by placing the end onto the os, rotate the spatula 360 degrees.

                                                               i.      Use the sharp end for nulliparous

                                                              ii.      Spread sample on the slide.

                                                            iii.      Fix using a fixation solution (or pretend that you are) (the proper name is called cytological fixative)

c.        You may use a cytobrush (the one that looks like a toilet cleaner) for another slide

                                                               i.      Insert the end of cytobrush into the cervix os

                                                              ii.      Rotate 180 deg. (360 may cause bleeding, quoting http://www.brooksidepress.org/Products/Military_OBGYN/Textbook/Pap/obtaining_a_pap_smear.htm)

                                                            iii.      Spread on slide, fix

d.       Done.

13.    Now remove the cusco’s bivalve speculum

a.        Unscrew the speculum

b.       Carefully pull out the speculum, rotating as you do so (reverse of what you did earlier)

c.        You may note the vaginal wall as you do so. Comment later.

14.    Done. Cover up the patient for dignity, and tell the patient that it is over.

“ thank you very much for your cooperation miss ---, I am done now. I hope it wasn’t too uncomfortable.”

Something like that.

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Thank, wash hands, leave.

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There are lots of things that are quite difficult to describe in words…. I might video myself.

Comment if you support this idea pls J