Clerking an o & g Case

CLERKING AND PRESENTING AN OBSTETRICS AND

GYNAECOLOGY HISTORY

PROF. DR. ZAINUL RASHID MD.RAZI,MD(UKM), Masters O&G (UKM), MRCOG(Lon),Doctorate of Med. (Nottingham), FICS (USA),

FRCOG (Lon)

CLERKING A CLINICAL CASEPURPOSE

History taking is to determine the medical problem/s and any assoc. cx

Physical examination is to support your clinical suspicions

Investigations is to confirm the diagnosis

Decide the line of management

Clerking and presenting as a medical student

In order to present a case well, a medical

student has to be a good ………

Detective – to investigate & determine the cause of the medical problem

Lawyer – to present the case convincingly, without reasonable doubt

Doctor – To decide the mode of treatment

Different types of presentation

Ward round presentation as a houseman – to brief the Consultant/Specialist on the latest development in the patient’s progress & management

Grand Ward Round presentation – Very brief and precise

Case presentation over the phone to inform your senior person to decide further management esp. during the early mornings – Direct to the point

Long Case presentation for medical student examination

PRESENTING A CLINICAL CASE Different from your clerking - Std. Format

Not to present everything that you have clerked and examined or what the patient told you !!!

Presentation is to highlight the relevant points pertaining to the current medical problems

To highlight any relevant past medical history that may or may not be related to the current clinical problem

HISTORY TAKING - HPI

Most patients know why they are admitted

Direct problem-orientated questions when the problem is obvious

Use check list only when you are still not sure what the problem is

HISTORY TAKING - HPICHECK LIST FOR O & G CASE History of Present Illness Past Obstetric History Contraception History Gynaecological History Past Surgical History Past Medical History Past Family History Social History

HISTORY TAKING - HPI OBSTETRIC CASEPatient’s Personal Data & Complaints

Name : LMP :

Age : Menses :

Parity : EDD :

Race : POA :

Occupation/housewife :

Chief Complaints :

Duration :

Reason for admission :

THE INTRODUCTION OF A LONG CASE

The ‘intro’ is a very important opening sentence to make for students who are going to present a long case.

It will immediately tell the examiners whether the student is able to grasp or understand the overall problems of the patient

It will reflect his/her maturity as a doctor

THE INTRODUCTION What must be highlighted ? - Any relevant history that will have a bearing on the mx &

outcome of the current problem

What is the aim ?

- To impress the examiners that you are aware of the implication of any associated history to the current problem

What does it indicate ?

- That you have a broad overview of the whole medical problem in this patient maturity !

THE INTRODUCTION OF A LONG CASE

DO NOT GO INTO TINY DETAILS

IN THE INTRO YET ! LEAVE IT FOR

THE HPI / MH / SH etc……..

Not to tell the diagnosis straightaway !

HISTORY TAKING - HPI OBSTETRIC CASEName : Mageswary LMP : 15/9/2003

Age : 25 years Menses : regular 28-30 days

Parity : G3P2 EDD : 22/6/2004

Race : Indian POA : 32 weeks

Occupation/housewife : Rubber-tapper

Chief Complaints : Painless PV bleeding

Duration : 1 day

Reason for admission : Further Mx

A TYPICAL MEDICAL STUDENT INTROMadam Mageswary a 25 years old G3P2 LMP 15/9/03,

EDD 22/6/2004 POA 32 weeks Indian rubber-tapper

admitted for painless PV bleeding x 1 day

INTRODUCING AN OBSTETRIC CASE

THE INTRODUCTION SENTENCE

Madam Mageswary is a 25 years old Gravida 3 para 2

Indian rubber-tapper at 32 weeks POA who is

admitted for painless PV bleeding of 1 day duration

for further management.

Compulsory inclusions

1. Name 5. Occupation / Housewife

2. Age 6. POA

3. Parity 7. Complaints

4. Race 8. Reason for admission

What is missing in the Intro compared to the typical medical student ?


THE INTRODUCTION SENTENCE


Indian rubber-tapper at 32 weeks POA who is



THE SECOND SENTENCE

Her LMP was on the 15th of September last year. She

has regular 28-30 days menstrual cycle. Therefore,

her EDD is on the 22nd of June, 2002 and she is

currently at 32 weeks POA.


However, not all cases are straight forward !!

They might have some important facts that

need to be highlighted in the introduction.

So,

You need to highlight these facts in the Intro

if it is relevant, especially when it may affect

the management of this pregnancy !!

Eg. - Known DM, heart disease

INTRODUCING AN OBSTETRIC CASEWITH A MEDICAL PROBLEM - DM

INTRODUCTION SENTENCE


Indian rubber-tapper who is a known diabetic

currently at 32 weeks POA and admitted for painless

PV bleeding of 1 day duration for further

management.

Don’t have to elaborate about the treatment,

complication yet !

Keep it for the HPI / MH.

INTRODUCING AN OBSTETRIC CASEWITH H/O LSCS


Madam Mageswary is a 25 years old G3P2 Indian

rubber-tapper with a history of one previous

caesarean section currently at 32 weeks POA and



THE SECOND SENTENCE





INTRODUCING AN OBSTETRIC CASEWITH AN ABN PARITY - G4 P2+1


Madam Mageswary is a 25 years old Indian rubber-

tapper in her fourth pregnancy with a history of 1

miscarriage currently at 32 weeks POA and admitted

for painless PV bleeding of 1 day duration for further

management.

THE SECOND SENTENCE





INTRODUCING AN OBSTETRIC CASEWITH NO COMPLAINTS



Indian rubber-tapper currently at 32 weeks POA who

admitted for further management of a raised blood

pressure but otherwise she- has no symptoms.

- is asymptomatic

- has no complaints

PRESENTING THE HISTORY

Always present as a third person.

Don’t have to say everytime when you start a

sentence,

“According to the patient, ......”

“The patient said that ......”

.....BECAUSE IT HAS TO BE FROM THE PATIENT !!!

WHO ELSE !!!!!

UNLESS YOU USE AN INTERPRETER !!!

PRESENTING AN OBSTETRIC CASE- H/O PRESENT PREGNANCY

Present Pregnancy

Planned pregnancy/Unplanned, wanted ? Diagnosis of pregnancy - UPT / ultrasound First booking - POA ? Where

- BP, Weight, Urine (sugar/protein),

- Uterus was corresponding dates ? Subsequent follow-ups

- Regular ? Uneventful ? Ut = date

- Weight gain acceptable ?

- Any blood investigations / ultrasounds ? Current complaint - HPI Fetal condition up till today/admission - FM good ?

PRESENTING AN OBSTETRIC CASE- HISTORY OF PRESENT PREGNANCY

Present Pregnancy

This is a planned pregnancy. She knew that she was pregnant when she missed her period in April, 2002.

She had a pregnancy test in May, 2002 at POA of 6 weeks which tested positive. The early part of the pregnancy was associated with excessive vomiting but did not require any admission.

She had her first booking at POA of 16 weeks at a government clinic. At this visit, she was told that her BP was normal, there was no proteinuria or glycosuria. The uterus was corresponding to her dates and she weighed 54 kg.


Present Pregnancy ( cont....)

The pregnancy had progressed well. She had several ultrasounds performed and was told that the baby was growing well.

However, 2 days prior to admission, she noticed slight per vaginal spotting. It was not associated with any abdominal pain, trauma or sexual intercourse. The bleeding remained slight until the day of admission. There was no fainting episodes

While she was in the ward, there was no further episode of PV bleeding

Uptill today, the fetal movements had been good


Always Imagine that you are managing the case and

note any deviation from the usual norm in terms of

patients’ management when you take the history.

Be critical during the case presentation esp. when

there is a deviation from the usual norm.

eg. - Despite her severe anemia, she was not given

any blood transfusion.

eg. - She was told that she was having a low lying placenta and would require admission. However, the patient refused and had continued as out-pt Tx


Be OBJECTIVE in your presentation ! Be clear about

why you are presenting the various complaints.

Typical Medical Student Presentation of the HPI

She had no epigastric pain, no visual disturbances,

and no nausea and vomiting. She had no dysuria, no haematuria and no increase in urinary

frequency.

What are you trying to tell the examiners ?

Don’t keep them guessing about what is in your mind.

Be direct about it !

PRESENTING AN O&G CASE- BE OBJECTIVE

Be clear about why you are presenting the various

complaints.

A Good Medical Student. She had no signs and symptoms suggestive of

impending eclampsia such as epigastric pain, visual disturbances etc.

She had no problem suggestive of urinary tract infection such as dysuria, haematuria and urinary frequency.

She did not have any evidence of decrease effort tolerance such as dypsnoea or palpitations

CLERKING THE GYNAE HISTORY

GYNAE / MENSTRUAL HISTORY

Menses - regular/irregular and what is the range ?

- flow normal / minimal / heavy ?

- duration of flow ?

- Any dysmenorrhoea

Sexual Intercourse - Any dyspareunia ?

- Superficial or deep ?

Any other gynae problems such as PV discharge ?

Any pap smear done ?


TAKING THE GYNAE / MENSTRUAL HISTORY

Menses - regular 12 28-30 days

5-7 days

- menorrhagia°, dysmenorrhoea°

No pap smear done.

PRESENTING GYNAE / MENSTRUAL HISTORY

Since menarche at 12 yrs old, her menses had been

regular of 28 - 30 days cycle with normal flow for 5 - 7

days with only slight dysmenorrhoea not requiring any

medication. She never had a Pap Smear done before.


TAKING THE GYNAE / MENSTRUAL HISTORY

Menses - irregular 12 1-3 months

5-7 days

- minimal flow, dysmenorrhoea°

No pap smear done.

PRESENTING GYNAE / MENSTRUAL HISTORY

Since menarche at 12 yrs old, her menses had been

irregular between 1-3 months. The flow was minimal

for 5-7 days with no dysmenorhoea. She did not seek

Tx for this problem.

She never had a pap smear done.

PAST OBSTETRIC HISTORYLIST THE PREVIOUS PREGNANCIES

Year of deliveries

The health institution for the delivery etc.

TYPE OF DELIVERIES - SVD, LSCS

POA at delivery

Any medical problems

Miscarriage - POA, cause ?, ERPOC?

Post delivery cx

Babies - weight, sex, abN, neonatal cx, alive/dead

PAST OBSTETRIC HISTORY

CLERKING THE PAST OBSTERIC HISTORY

1992 - FTNP, SVD, MHKL Boy, 2.8kg, alive & well 1993 - FTNP, SVD, MHKL Boy, 3.1kg, alive & well 1995 - FTNP, SVD, MHKL Girl, 3.2 kg, alive & well 1996 - FTNP, SVD, MHKL Girl, 3.4 kg, alive & well 1997 - FTNP, SVD, MHKL Boy, 3.5 kg, alive & well

How do you present this obstetric history ?

PAST OBSTETRIC HISTORYPRESENTING THE PAST OBSTERIC HISTORY

A typical medical student will recite the whole

POH from the beginning until the end for eg.

In 1992, she had a FTNP and delivered a baby boy by SVD at MHKL. The baby weighed 2.8kg and is alive & well

In 1993, she had a FTNP and delivered a baby boy by SVD at MHKL. The bay weighed 3.1kg and is alive & well ……………………..etc,etc

1995 - FTNP, SVD, MHKL Girl, 3.2 kg, alive & well 1996 - FTNP, SVD, MHKL Girl, 3.4 kg, alive & well 1997 - FTNP, SVD, MHKL Boy, 3.5 kg, alive & well

OBSTETRIC HISTORYPRESENTING THE PAST OBSTERIC HISTORY

Try to summarise where ever possible

For eg.

- She had delivered 5 children between 1992

till 1997 which were all uneventful

spontaneous vaginal delivery with babies

weight ranging between 2.8 to 3.5 kg. All

the children were normal, alive and well. If the POH is complicated, give the main findings first.

OBSTETRIC HISTORYPRESENTING A COMPLICATED PAST

OBSTERIC HISTORY

Past h/o LSCS

For eg. - She had delivered 5 children between 1992

till 1997. All the children were delivered by

spontaneous vaginal delivery except for the third

one which was delivered by caesarean section due to

fetal distress. The post-operative period was

uneventful. The babies weights ranged between

2.8 to 3.5 kg. All the children were normal, alive and

well.

OBSTETRIC HISTORY

PRESENTING A COMPLICATED PAST

OBSTETRIC HISTORY

Past h/o Miscarriage

- Which trimester was it ?

- Was it a confirmed pregnancy ? UPT/Ultrasound?

- Was any ERPOC performed ?

- Was there any complication such as infection /

foul smelling PV discharge, delayed period ?


OBSTERIC HISTORY - h/o Miscarriage


till 1997 with a history of one miscarriage in the third

pregnancy. The miscarriage at 9 weeks POA was a confirmed pregnancy

diagnosed by ultrasound. An ERPOC was performed and there was no complication following the procedure.

The rest of the pregnancies were delivered by

spontaneous vaginal delivery The babies weights ranged between 2.8 to 3.5 kg. All the children were normal, alive and well.


OBSTERIC HISTORY

Past h/o Intrauterine death

- What was the POA/POG?

- Was there any ppt factor eg trauma ?

- How was it diagnosed ?

- Mode of delivery and how was labour started ?

- Was there any complication such as infection,

foul smelling PV discharge after delivery ?

- Describe baby -sex, weight, MSB/FSB, any

AbN, placenta


OBSTERIC HISTORY - Intrauterine Death


till 1997 with a history of one intrauterine death in the

third pregnancy. The IUD occurred at 36 weeks POA. There was no precipitating cause

and it was diagnosed following a c/o decreased fetal movements. The delivery was induced and a baby boy weighing 2.6 kg was delivered by a normal vaginal delivery. The baby was macerated but there was no abnormality detected. The placenta had gross infarction.

The rest of the pregnancies were delivered by…...

CLERKING THE CONTRACEPTION HISTORY

Clerking the Contraception History

How many children does the couple wants ? Is the family complete ? What form of contraception are they practising or intend

to use ? What have they used before ? Do you think their compliance can be assured ? What contraception do you think is the most suitable for

them based on their history and your assessment ? Are they aware of the side-effects and complications as

well as the advantages and disadvantages ? How long do you suggest they should use this method ?

CLERKING THE CONTRACEPTION HISTORY

Presenting the Contraception History

The couple wishes to have four children. After this pregnancy, they wish to use the intra-uterine contraceptive device because it is more reliable and she cannot be sure of her compliance using the OCP or the injectables.

I have explained to the couple regarding the advantages and disadvantages of this method.

The couple is aware of the side-effects and the complications that can arise with this method.

They intend to use it for about 2 years.

CLERKING THE MEDICAL HISTORY


- When was the disease diagnosed ?

- What is the duration of the illness?

- What medication is she on ?

- Is she compliant in taking the medication ?

- Is the medical problem well controlled ?

- Is there any complications secondary to the

disease ?


CLERKING THE MEDICAL PROBLEMKnown diabetic diagnosed since 1990.

On daonil 5 mg tds and taking medicine well.

DM well controlled.

No cx.

PRESENTING THE MEDICAL HISTORY

She is a known diabetic diagnosed in 1990.

She had been on Daonil 5 mg tds and her

compliance had been good. Her diabetes is

currently well-controlled with no complications

thus far.

CLERKING THE SURGICAL HISTORY

CLERKING THE SURGICAL PROBLEM

Known case of thyrotoxicosis. Had thyroidectomy in Malacca in 1994. Not on any medication. Euthyroid state.

PRESENTING THE SURGICAL HISTORY

She is a known case of thyrotoxicosis and had

undergone thyroidectomy in 1994 in Malacca

GH. She is now in a euthyroid state and does

not require any medication.

CLERKING THE FAMILY HISTORY

CLERKING THE FAMILY HISTORY

Father diabetic - on daonil tds well controlled Mother diabetic - on insulin injection, poorly controlled Eldest brother - diabetic, on metformin, well-controlled

PRESENTING THE FAMILY HISTORY

She has a strong family history of diabetes. Both

her parents and one of her sibling are diabetics

on treatment. However, her mother’s diabetes

is poorly controlled despite on insulin injection.

CLERKING THE SOCIAL HISTORY

Purpose of the social history

To determine whether there is any implication of her social history that may affect her current medical/obstetrics condition

Is the social life affecting her clinical

condition or is the clinical problem affecting her social life ?

Who is taking care of her family while she is in the ward ?


Typical medical student presentation of the

the social history

She works as a clerk earning $600 per month.

Her husband works as a policeman earning $1000 per month.

They live in a house with adequate water and electric supply.

She does not smoke or consume alcohol

CLERKING THE SOCIAL HISTORYEg. Anaemia case

Is the family income adequate Is the diet sufficient in proteins, vitamins and the essential

elements ? Is she prone for worm infestations due to

surrounding living condition ? Is the anemia affecting her family, work & social life ?

Presenting the social historyThe combined income of the family was less than a

$1000 ringgit which was barely enough to make ends

meet. Their daily diet was insufficient in proteins and

essential vitamins. They lived in a squatter area where

they are prone to worm infestations. She could hardly

cope with the daily house work and child care


Eg. Heart Disease

Is her living condition favourable for her heart condition - flat, ground house etc.

Has the heart disease any bearing on her work life in terms of exertion or stress ?

Presenting the social history

The couple live in the 4th floor of a flat house

which does not have any lift and it is

strenuous for her to climb up the stairs. Her

work as a cleaner too was making her effort

tolerance worst.


Eg. Placenta Previa

Does her working condition involves a lot of movement or strenuous work ?

What about her work while she is admitted ? Who is taking care of her family while she is

admitted ?

Presenting the social historyThe patient is a teacher and her classroom is on the

third floor. The headmaster had been informed of the

need for prolonged hospital stay and a temporary

teacher will be arranged as a replacement.

Her mother-in-law will be looking after her children

while she is in the ward.

SUMMARY OF HISTORY The summary should include all the relevant history

and the probable diagnosis Don’t have to go into all the small details such as

name, HPI of current problem again, etc

Presenting the summary

This is a 32 years old Gravida 5 Para 4 Indian

housewife, a known diabetic, currently

at 32 weeks POA who is admitted for painless

per vaginal bleeding due to placenta previa for

prolonged bed rest and awaiting delivery.

HISTORY OF PRESENT ILLNESS

When and where should you start the HPI ?

If no other problems, start with the patient’s current problem.

If patient has an important background history, such as diabetes/hypertension that will affect the current management, then this should be highlighted from the beginning before starting the current problem.

Eg. She is a known case of hypertension since the age of 37 yrs currently under good control. The present problem started 2 weeks ago when .......


When and where should you start the HPI ?

If the patient had a previous similar history as the current problem that is possibly a continuation, then the history should start from the previous history and they should not be separated !

Eg.

Her problem started when she was 26 years old when she first developed severe dysmenorrhoea. She was investigated and was found to be suffering from endometriosis. She was treated with oral medication (Danazol) for 6 months after which she was well. Six weeks ago, she started to have similar menstrual pain which was associated with.......


How do you present the different timing of the

events ? By dates ? By year ?

It is better to present according to the age and the number of days/weeks/years ago instead of the dates. Too confusing !

Eg. She started to have irregular menses when she

was 18 years old until now. However, her periods

started to become painful for the past 2 months.

Instead of

eg. She started to have irregular menses in 1987 until

now. Lately, since June this year, her periods

started to become painful.

How do you present the different places that the patient went to for treatment? By name? By town?

Students should know the names of the various places

that the patient went to during the clerking but when

presenting....

Students should not state the name of the medical centre or doctor’s clinic when referring to private practices such as Ampang Puteri Hospital, Samuel’s clinic etc... So what !

Students should also not state the names of the Government health centre that the treatment was seeked by the patient.

How do you present the different places that the patient went to for treatment? By name ? By town?

During presentation, students only need to mention

the levels of the health centre. Not the names !

For eg.

For private centres ;

The patient went to a general practitioner for the abdominal pain and she was subsequently referred to a private hospital for further management.

For government health agencies ;

The patient first went to a Pusat Kesihatan Besar for the above complaints. She was subsequently referred to the District hospital for further management.

CONCLUSION

Case presentation basically is telling intelligently the medical story of a patient who come to the hospital for further management.

It is your duty to be able to select which history are relevant or irrelevant to the current case prior to presentation. DO NOT PRESENT EVERYTHING THAT THE PATIENT SAY !!

A good medical student will be able to give constructive comments regarding the management of the patient who had not been managed according to the usual practice.

CONCLUSION - Constructive comments

Even though the patient was diagnosed to have placenta previa, she was allowed to go home without any advice.

Fortunately for the patient, she did not develop any PV bleeding when she was staying at home despite having a placenta previa major.

Surprisingly, no antibiotics was prescribed by the GP to the patient despite her earlier complaints of a foul smelling PV discharge following an ERPOC.

These comments will show your maturity as a medical

officer and will score points in the clinical exam.

Documents

Clerking an o & g Case