Manned OSCE File, Slides of History

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Manned OSCE File

Done by:

Allulu Alsulayhim, Atekah Kadi, Bayan AlMugheerah, Dania Alkelabi, Doaa Abdulfattah, Haifa alwael, Haneen

alsubki, Hanin Bashaikh, Laila Mathkour, Layla AlBreacan, Leena Alwakeel, Maha Alghamdi, Munirah Aldofyan,

Muneerah Alzayed, Njoud Alenezy, Noura AlShabib, Raneem Alghamdi, Rawan Alqahtani, Razan Alotaibi,

Shahd Alsowaidan, Shatha Alghaihb, Wejdan Alzaid, Zaina Alkaff.

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Editing file:

Important | Notes | Extra | Hacker and Moore’s

Here

 436 Slides & Notes

 436 Doctor’s Notes.

 435 teamwork

 Books: Hacker and Moore’s, Ten Teacher Book

 Teach me OBGYN

 Geeky Medics

Laila Mathkour, Shrooq Alsomali

o OSCE exam is 15 stations. 5 Manned and 10 Unmanned “SAQs” stations.

o This file contains manned stations only (history, examination, counseling and discussion). At these stations there will be an

examiner and stimulated patient with you. While in SAQ there will be you and your paper only.

o Don’t forget to check SAQ’s File after finishing this file.

o This file references are previous cases, doctor notes, and theoretical lectures, most of cases came previously so please don’t skip

any case.

o For the history part: focus on the specific histories but please go through general history in case of any new station. You will

have 5 minutes so please try to ask the specific related questions.

o For the examination part: you have to speak and verbalize what you’re doing, and don’t forget to mention (washing hands,

chaperone, privacy and all inspections elements ) because all of them are in the check list.

o For the counseling, there is one page to explain how to approach any counseling stations, please go through it before studying

the counseling part it will make it easier.

o You may notice the difference in the number of pages between us and 435, because we have added some missing stations and

extra explanations and pics.

Thanks to everyone who worked on this file ❤ It is a single file but requires a lot of effort and time in order to complete it.

Thank you all ❤

Table of content:

Topic Page Topic Page

General History General Obstetrics History 3 Counseling Stations Counseling in General 34

General Gynecology History 6 OCP for Fist Time Counseling 35

Focused History History of Infertility 8 OCP with breastfeeding

Counseling

History of Postmenopausal Bleeding 11 Dysfunctional Uterine

Bleeding Counseling

History of Cervical Incompetence 13 Pregnant Not Immune to

Rubella Counseling

History of Ectopic Pregnancy 14 Recurrent Abortion

Counseling

History of History of Early Pregnancy

Bleeding

16 Diabetes with Pregnancy

Counseling

History of PROM 17 PCOS Counseling 43

History of Vaginal Discharge 19 Preconception Counseling 44

History of Dysmenorrhea 20 Preeclampsia Counseling 46

History of postpartum Hemorrhage 22 Discussion Episiotomy Discussion 47

Examination General and Focused Abdominal

Obstetric Examination

24 Menopause Discussion 48

General Gynecological Examination 27 Cervical cancer Discussion 49

Pelvic Examination 28 Ovarian cancer Discussion 50

Placental Delivery 32 Antenatal Surveillance

Discussion

Preterm Labor Discussion 53

2 This information is important for planning the method of delivery in the present pregnancy.

3 This may alert the physician to the possibility of an unusually longer or short labor

4 Maternal complications such as urinary tract infections, vaginal bleeding, hypertension, postpartum complications may be repetitive; such

knowledge is helpful in anticipating and preventing problems with the present pregnancy.

5 This information may give indications of gestational diabetes, fetal growth problems, shoulder dystocia, or cephalopelvic disproportion.

6 This may indicate certain genetic risk factors.

7 The gestational age of any spontaneous abortion is of importance in any subsequent pregnancy.

8 A good menstrual history is essential because it is the determination for establishing the expected date of delivery. assumes a normal 28-day

cycle, and adjustments must be made for longer or shorter cycles. Any bleeding or spotting since the last normal menstrual period should be

reviewed in detail and taken into account when calculating an EDD.

9 If she says it’s irregular, ask here more she may say every month it gets delayed 2 days then this regular.

• G……P……A……. Gestational Age………………. LMC…………… EDD…………………….
• Type of conception is it spontaneous? or Ivf?
• Pregnancy detected by ……………. and confirmed by ………………
• Number of fetuses …………… (chorionicity), US at 14 weeks: GA ……….…., placenta location…………….…. (all by ultra sound)
• Have there been any other problems in this pregnancy? (bleeding, contractions, vaginal discharge, loss of fluid, fever, GDM, GHTN)

discharge usually normal but we mean gush of fluid here.

• Booked as if it’s her first visit to your clinic or follow up? …………………. Numbers of antenatal visits………………. and if there were any

complications………………... If booked ask for her previous ultrasounds and how was her pregnancy from the beginning.

• Blood transfusion…………….…. Rh typing…………….….
• Fetal movement: detected? if yes, when was the first movement ……………………. does she notice diminished or changes in the movement

…………….…. (fetal movement can be detected in the 17-20 weeks)

• Any invasive tests or procedures has been done? If yes, when? …………… why? ……………… any Cerclage?…………….
• Any hospital admission? If yes, when? ......................... why? …………………… how it was controlled?………………………

5. History of Previous pregnancies :

Take details of each prior pregnancy start from first to last pregnancy. If the number of children is three or less, details should be given to all of

them. However, if the number of children is more than three just mention the age of the eldest and youngest + the details of any delivery that

isn’t normal vaginal, otherwise just say (the eldest is .. the youngest is .. and they all were normal deliveries)

For Term pregnancies (>20 weeks): For Other pregnancies (<20 weeks)

• Type of conception spontaneous or IVF?........................
• Date of delivery ……………. Location of delivery ………….….
• Type of delivery: normal vaginal?, CS? If yes, why? ……………

assisted? (vacuum, forceps), was episiotomy induced, If yes why?

2

• Duration of labor in hours

3 ……… Duration of gestation in weeks….….

• Number of children’s (in one pregnancy) ……………………………
• Type of anesthesia…………. any complications from it?..............
• Any history of preterm delivery? ………….. unexplained stillbirth?
• Maternal complications

4 : antenatal? Intrapartum? Postpartum? If

yes, what?…………… how it was controlled? ………………..

• Fetal complications? If yes, what?………..…… how it was controlled?
• For babies: Newborn weight

5 ……………..…. Age ……………..….

Gender

6 ……………..…. baby ICU admission? If yes, why? ……….. for

how many days? ………………… Anomaly? ……………..…. baby’s Present

health, still alive? Breastfeeding?....................

• Type of conception spontaneous or IVF?........................
• Miscarriage? If yes Clarify the gestation of the

trimester………................ the cause? ……………..….

• Date of termination of pregnancy ……………. Location of

termination of pregnancy …………….

• Type of termination of pregnancy

7 : …………………. medical or

surgical managements?

• Type of anesthesia…………………. any complications from

it?.................................

• Maternal complications: antenatal? Intrapartum? If yes,

what?…………… how it was controlled? ………………..

• Molar pregnancy? If yes Clarify medical or surgical

managements. ……………..….……………..….

• Ectopic pregnancy? If yes Clarify the site and the

management…………………

6. Menstrual History

8

Age of menarche……... regular or irregular?......... Menstruation duration………. Menstrual cycle

9 ……... Menstrual volume (no. of pads & fullness,

make sure it is not for hygiene) ……..… any intermenstrual bleeding?........... impact on her life? ………. Dysmenorrhea, menorrhagia, midcyclic

pain? If yes, take full SOCRATES history, Date of LMP………. Age of menopause……….Menopausal symptoms………..… any postmenopausal

bleeding?.............

7. Gyne History:

10 Estrogen containing medications (e.g. combined oral contraceptive) would be contraindicated

11 Particularly cats (which carry a risk for toxoplasmosis).

• Ectopic pregnancy? Endometriosis? If yes, when? ………………… how it was controlled?………………………
• Previous infections? ………………. When? how it was controlled?………………………
• Last Pap smear ……………..…. was it normal? ……………..…. If it was abnormal what was the management? ……………………
• Malignancies? (Cervical, endometrial, ovarian) ……………..….

8. Sexual History:

Regular sex?................ Protective sex? …………… any Pain(Dyspareunia)? ………… any bleeding(postcoital bleeding)?..................

9. Past Medical History:

Renal diseases, SLE, migraine with aura

10 , VTE, bleeding disorder, breast cancer. etc. In addition to common disorders, which are known to

affect pregnancy outcome, all serious medical conditions should be recorded.

10. Medication History:

 If any, what? ………….. why? ……………. Duration? ………………

 Supplements history.

• History of contraception. Type? …………….. duration? ………………. Compliance? …………………. To see if we can use her LMP as guide or not. If

she was using OCP and stop, If she get pregnant without periods that’s LMP is not reliable because it was withdrawal bleed not an

ovulation bleed then go by US but if get pregnant with 2 or more periods then that is an ovulation bleed. Also this information is important

for risk assessment. Oral contraceptives taken during early pregnancy have been associated with birth defects, and retained intrauterine

devices (IUDs) can cause early pregnancy loss, infection, and premature delivery.

11. Past Surgical History:

• If any, what? ………. When? …………. Complications? ………... trauma?.......... (like fractured pelvis may result in diminished pelvic capacity)
• Type of anesthesia…………. any complications from it?..............
• Previous gynecological surgery. scars can lead to adhesions → weak uterus may rupture during contraction → will go with CS. And to

know if she took GA with no complications ( sometimes she could have an emergency C/S and there is no time for epidural anesthesia you

need to use GA)

12. Blood transition History:

If any, when? ………….. why? ……………. How many? ………………. Any complications? …………………

13. Allergy History:

14. Vaccine History:

15. Family History: (for both partner its important to know about any family history that can impact on baby)

• Hereditary illness: DM, HTN, thalassemia, sickle cell disease, hemophilia? ……………..….……………..….
• Congenital defects: neural tube defects? ………………. Down syndrome? …………… Twins? ……………..….……………..….
• Malignancy? (Breast, ovaries, uterine, colon, prostate cancer) ……………..….……………..….

16. Psychiatric History:

Postpartum blues or depression? ………….. Depression unrelated to pregnancy? …………….. Major psychiatric illness? …………….

17. Social History:

Illicit drugs? Alcohol? Smoking? Family Support? domestic violence? Animal’s contact

11 ? Physical activity? Diet?

18. Review of systems:

19. Summary

18 This may alert the physician to the possibility of an unusually long or short labor.

19 Maternal complications such as urinary tract infections, vaginal bleeding, hypertension, postpartum complications may be repetitive; such

knowledge is helpful in anticipating and preventing problems with the present pregnancy.

20 This information may give indications of gestational diabetes, fetal growth problems, shoulder dystocia, or cephalopelvic disproportion.

21 This may indicate certain genetic risk factors.

22 May give insight on present complain

23 Estrogen containing medications (e.g. combined oral contraceptive) would be contraindicated

• Duration of labor in hours

18 ……… Duration of gestation in

weeks….….

• Number of children’s (in one pregnancy) ……………………………
• Type of anesthesia…………. any complications from it?..............
• Any history of preterm delivery? ………….. unexplained stillbirth?
• Maternal complications

19 : antenatal? Intrapartum? Postpartum? If

yes, what?…………… how it was controlled? ………………..

• Fetal complications? If yes, what?………..…… how it was controlled?
• For babies: Newborn weight

20 ……………..…. Age ……………..….

Gender

21 ……………..…. baby ICU admission? If yes, why? ……….. for

how many days? ………………… Anomaly? ……………..…. baby’s

Present health, still alive? Breastfeeding?....................

• Type of termination of pregnancy: …………………. medical or

surgical managements?

• Type of anesthesia…………………. any complications from

it?.................................

• Maternal complications: antenatal? Intrapartum? If yes,

what?…………… how it was controlled? ………………..

• Molar pregnancy? If yes Clarify medical or surgical

managements. ……………..….……………..….

• Ectopic pregnancy? If yes Clarify the site and the

management. ……………..…………..….

6. Sexual History:

22

If the lady is sexually active ask about:

Regular sex?................ Protective sex? …………… any Pain(Dyspareunia)? ………… any bleeding(postcoital bleeding)?..................

7. Past Medical History:

Fibroids, endometrioses, Renal diseases, SLE, migraine with aura

23 , VTE, bleeding disorder, breast cancers, any thyroid problems.

8. Medication History:

 If any, what? ………….. why? ……………. Duration? ………………

• History of contraception. Type? …………….. duration? ………………. Compliance? …………………. Complications? …………… (Ex. Amenorrhea,

thromboembolic disease with hormonal contraceptives, dysmenorrhea, menorrhagia, pelvic infection with IUD, contraceptive failure

with diaphragm or other barrier method)

9. Past Surgical History:

• If any, what? ……………. When? ………………. Complications? ……………..…. trauma?...........
• Type of anesthesia…………. any complications from it?..............
• Previous gynecological surgery. scars can lead to adhesions → weak uterus may rupture during contraction.

10. Blood transition History:

If any, when? ………….. why? ……………. How many? ………………. Any complications? …………………

11. Allergy History:

12. Vaccine History:

13. Family History:

• Hereditary illness: DM, HTN, thalassemia, sickle cell disease, hemophilia? ……………..….……………..….
• Endometrioses? …………… Fibroids?..................
• Malignancy? (Breast, ovaries, uterine, colon, prostate cancer) ……………..….……………..….
• Congenital defects: neural tube defects? ………………. Down syndrome? ……………

14. Psychiatric History:

any blues or depression? ………….. Depression unrelated to pregnancy? …………….. Major psychiatric illness? …………….

15. Social History:

Illicit drugs? Alcohol? Smoking? Family Support? domestic violence? Animal’s contact? Physical activity? Diet?

16. Review of systems:

17. Summary

24 Midcycle pain wich increase in vaginal secretions (both are usually indicative of ovulatory cycles)

25 Bleeding between her periods.

• In the specific history we will focus on the questions that is related to each case, so please make sure to go through the general history

first to know the questions that asked for full history.

• In infertility history there is questions for both partners.
• Infertility is: Inability to become pregnant despite 12 months of trying to conceive without using contraception in women <35 years-

old1. Or 6 months in women >35 years-old.

Case: A couple came to your clinic complaining of infertility. Please take history from them

A. What are you going to ask the wife in the Hx?

Personal Information:

• Name.
• Age (female fertility declines with age and age is one of the most important prognostic factors for prognosis and treatment outcome).
• Marital Status (Age and years of marriage and if there are any pregnancies with previous partners) if they married 5 months ago this is

normal duration to not get pregnant.

• Occupation (if there are any exposures to solvents, lead, paint, pesticides, metal fumes, vibration, radiation)
• Residency (Sometimes the wife is in one city, and the husband works in another city and this may be the cause of infertility)

Chief Complaint:

Can’t get pregnant. For how long (duration)? important to differentiate between primary infertility and secondary infertility.

• Primary infertility refers to partners who have not become pregnant after at least 1 year having sex without using birth control methods.
• Secondary infertility refers to partners who have been able to get pregnant at least once, but now are unable.

History of presenting Illness:

Ask details about infertility:

• For how long?
• Did they try any infertility medication? If yes, when? ………. Any response? ………….What was the outcome?
• What was the type of ovulation induction? (Clomiphene Citrate tablets, Human Menopausal Gonadotropins, Intrauterine insemination).
• Previous IVF?
• Any hyperpresence?
• Methods to monitor ovulation: (cervical mucus, BBT "basal body temperature", LH Kit).

Ask about associated risk factors: (You can ask for symptoms in details or just ask about diseases in the past medical history)

• PCOS symptoms: hirsutism, acne, wight change, acanthosis nigrican.
• Menopausal symptoms: hot flushes, sleeping difficulties, night sweats and dry vagina.
• Pelvic inflammatory disease symptoms: pelvic pain, discharge.
• Gynecological problems? …………….. Anomalies? ………………………….
• BMI: (>29 or <19 will lead to difficulty conceiving).

Gyne History:

You want to know Is she is probably ovulating? So ask about Menstrual History:

• Age of menarche……… regular or irregular?......... Menstruation duration.……… Menstrual cycle ……..…. Menstrual volume (no. of pads &

fullness, make sure it is not for hygiene) ……………. any clot or flooding?........………. Menstrual cycle symptoms (dysmenorrhea,

menorrhagia, oligomenorrhea, discomfort, Irritability, Depression, Pelvic pain, Vaginal dryness, Vaginal discharge, mittelschmerz)

24 ?

Date of LMP……….

• Intermenstrual bleeding (metrorrhagia)?

25

• Previous infections? ………………. When? how it was controlled?………………
• Last Pap smear ……………..…. was it normal? ……………..…. If it was abnormal what was the management? ……………………

Ob history:

In case of secondary infertility ask about:

- G….P….A……

• Type of conception spontaneous or IVF?........................

History of Infertility

Came 1 time before

Very important

Family History:

History of infertility.

Social History:

Illicit drugs? Alcohol? Smoking?

Discussion Questions:

• What are the etiologies of infertility?

o Female causes: ovulatory dysfunctions, tubal, pelvic and uterine abnormality.

o Male factors: decreased sperm count, decreased motility or low normal forms.

• What is the best investigation for ovulation?

o Normal TSH.

o Prolactin

o Evaluation for ovulation: Progesterone day 21.

o Basal body temperature.

o Pre-ovulatory cervical mucus.

o Urinary LH.

o Semen analysis

• What are the components of semen analysis?

o Sperm concentration >15million.

o Semen volume 2 - 5 ml.

o Normal morphology 4%.

o Sperm motility > 50%.

o pH 7.2 – 7.8.

o Liquefaction time: less than 30 min.

29 The most serious cause of postmenopausal bleeding

30 The most common cause of postmenopausal bleeding

31 That may range from pink and watery to thick, brown, and foul smelling

32 Early menarche and late menopause are risk factors for endometrial cancer.

Case: 61 years old female with postmenopausal bleeding, take a focused history regarding the complaint.

Before starting, think what is the deferential diagnose and start to ask about their symptoms and risk factors to rule it out or

confirm the diagnose.

Possible causes: Endometrial cancer

29

, vaginal atrophy

30

, hormonal replacement therapy.

Personal Information:

Name……………………………………… Age………………. P……A……. LMC…………

Chief Complaint:

She presented Because of Postmenopausal bleeding. For how long (duration)?

History of presenting lines:

Ask about bleeding details:

• How many time since menopause?...........is it every day? ………. How much the amount (no. of pads & fullness, make sure it is not for

hygiene) any clot or flooding? Is there fresh blood (red) or old (darker, brown) blood?

• Other bleeding from other places? Any ER visiting?
• Progression? For example: Spotting until 2 days ago. Now it is like a period.
• Is it provoked bleeding: Is the bleeding spontaneous or after intercourse or defecation? This could indicate a cervical origin of the

problem, e.g. infections and malignancies or even hemorrhoids.

Ask about associated symptoms: (atrophy symptoms, endometrial cancer symptoms, pressures symptoms)

• vaginal dryness, vaginal burning, vaginal discharge

31 , postcoital bleeding, bloating, pain or burning with urination, more frequent

urinary tract infections, urinary incontinence, pain in the lower abdomen, back, or legs, weight loss.

Gyne History:

• Age of menarche……… Age of menopause? …………

32

was the menstruation regular?........ Menstruation duration.……… Menstrual cycle.

• Previous infections? ………………. When? how it was controlled?………………
• Last Pap smear ……………..…. was it normal? ……………..…. If it was abnormal what was the management? ……………………

Ob history:

Take details of each prior pregnancy from first to last pregnancy. History of infertility & nulliparity are risk factors for endometrial cancers.

Sexual History:

If she is sexually active ask about: Dyspareunia? ………… postcoital bleeding?..................

Past Medical History:

History of gynecological problems, breast cancer, thyroid disease, HTN and DM, Obesity, coagulopathy, Gallbladder disease.

Medication History:

• Aspirin, heparin and any anticoagulant medications, NSAIDs, Coumadin.
• History of contraception. Type? …………….. duration? ……………….
• History of hormonal therapy. If any, what? ………….. why? ……………. Duration? ………………
• History of chemotherapy, radiation therapy.

Past Surgical History:

• If any, what? ……………. When? ………………. Complications? ……………..…. trauma?...........
• Previous gynecological surgery.

Blood transition History:

If any, when? ………….. why? ……………. How many? ………………. Any complications? …………………

Allergy History:

Family History:

Malignancy? Breast, ovaries, uterine, colon.

Social History:

History of Postmenopausal bleeding

Came 1 time before

34 Could be the could if she works in the radiation area for example.

35 Also known as lupus anticoagulant syndrome and Hugh syndrome. This disorder is characterized by the presence of APL

antibodies, which are frequently linked to pregnancy losses.

36 Poorly controlled diabetes, as evidenced by high glycosylated HgA1c levels in the first trimester, are at a significantly increased risk

of both miscarriage and fetal malformation.

37 Because it's a risk factor to APLS.

38 Acquired condition of the uterus. In women with this condition, scar tissue or adhesions form in the uterus due to some form of

trauma.

Case: A 32 years old G 3 P1+2, she had 2 abortions. Take a focused history regarding the complaint.

Personal Information:

Name……………………………………… Age………………. occupation

34 ……………… P……A……. LMC……………

OB history: Take details of each prior abortions or complete pregnancy start from first to last pregnancy

• For each complete pregnancy ask about:
• Type of conception is it spontaneous? or IVf?
• Pregnancy detected by ……………. and confirmed by ………………
• Type of delivery: normal vaginal? CS? If yes, why? ……………

assisted? (vacuum, forceps), was episiotomy induced, If yes why?

• Duration of labor in hours.
• Any history of preterm delivery? ………….. unexplained stillbirth?
• Maternal complications: antenatal? Intrapartum? Postpartum? If

yes, what?…………… how it was controlled? ………………..

• Fetal complications? If yes, what?………..…… how it was controlled?
• Newborn weight ……………..…. baby ICU admission? If yes, why?
  • For each abortion ask about:
  • When?.............. Her age?............... Gestational

age?.................

• The cause? maternal and fetal causes, ask about if the baby

had any congenital problems. Most spontaneous

miscarriages are caused by an abnormal (aneuploid)

karyotype of the embryo.

• Any contraction felt, bleeding, rupture membranes, passing

of tissue.

• Type of termination of pregnancy: spontaneous, medical or

surgical managements?

• Maternal complications: antenatal? Intrapartum? If yes,

what?…………… how it was controlled? ………………..

Gyne History:

• Any anatomic abnormalities?

o Uterine septum (the anomaly most commonly associated with pregnancy loss)

o Hemiuterus (unicornuate uterus), Bicornuate uterus.

o Short cervix or collagen disorder.

• History of fibroids, Uterine polyps.
• History of incompetent cervix, trauma to the cervix.
• Previous infections? ………………. When? how it was controlled?…………………

Past Medical History:

Antiphospholipid syndrome(APLS)

35

, DM

36 , Thyroid disease, PCOS, Thrombosis

37 , Asherman syndrome

38 , infectious diseases (Rubella,

toxoplasmosis).

Medication History:

• If any, what? ………….. why? …………….
• History of contraception. Type? …………….. duration? ……………….

Past Surgical History:

Previous gynecological surgery, Cerclage, D&C, cone biopsy.

Family History:

Congenital abnormality or hereditary disease in the family.

Social History:

Alcohol? Smoking? Diet?

Discussion Questions:

History of Cervical incompetence

Came 1 time before

39 To know if she is pregnant or not

40 Nausea and fainting might indicate shock due to heavy (intra-abdominal) bleeding in ectopic pregnancy.

41 If she says it’s irregular, ask here more she may say every month it gets delayed 2 days then this regular.

42 can cause inflammation in the tubes and other nearby organs, and increase your risk of an ectopic pregnancy.

• If she has a history of painless dilation of the cervix and loss of pregnancy. What is the diagnosis? Cervical incompetence.
• What are you going to do for her for this pregnancy? When?

Cervical cerclage, performed at 13- 14 week. The stitch should be removed at 37-38 weeks’ pregnancy or whenever the patient goes

into labor.

• Mention one investigation you are going to do for her?

o US: The three ultrasound signs are shortening of the endocervical canal, funneling of the internal os, and sacculation or

prolapse of the membranes into the cervix.

o High vaginal swab & pap smear  for infections

Case: A lady presented to the ER complaining of lower abdominal pain with a Hx of amenorrhea for 6 weeks. Take a

focused history regarding the complaint.

Personal Information:

Name……………………………………… Age………………. P……A……. LMC

39 ……………

Chief Complaint:

She presented because of lower abdominal pain and amenorrhea stared with her 6 weeks ago.

History of presenting lines:

Start with SOCRATES for pain details:

• Where exactly the pain? Is it in one side of the pelvis or all over.
• Onset.
• Characteristic of the pain: is it sharp, colicky…etc
• Course of the pain: is it continues, intermittent.
• Radiation.
• Aggravating and reliving factors
• Severity.

The ectopic pain is usually sudden, continues very sever sharp pain that felt in the left or right iliac fossa and can radiate to the breast,

shoulders and back.

Ask about associated symptoms: (ectopic symptoms, UTI symptoms, appendicitis and IBD symptoms to roll it out)

o Vomiting

40 , nausea, vaginal bleeding.

o Urinary frequency, urgency, burning, fever, chills, diarrhea.

Gyne History:

o Menstrual History (to know the type of her amenorrhea): Age of menarche……… regular or irregular?......... Menstruation

duration.……… Menstrual cycle

41 ……..…. Menstrual volume (no. of pads & fullness, make sure it is not for hygiene) ……………. any clot or

flooding?........………. Midcycle pain. ………. Date of LMP……….

o History of pelvic inflammatory disease? gonorrhea, or chlamydia infections

42 ? …………. When? how it was controlled?

o Gynecological problems? …………….. Congenital uterine malformation?

o Previous ectopic pregnancy?

Ob history:

Take details of each prior pregnancy start from first to last pregnancy

History of Ectopic Pregnancy Came 4 times before

44 can be a result of recent aseptic procedures or of miscarriage which has been infected. It could also be a symptom of an infection

which in itself is correlated with miscarriage, e.g. malaria.

45 Sometimes UTI presents itself with fresh blood in the toilet or stains in her underwear

Case: 30 years old pregnant lady at 16 weeks of gestation presented with vaginal bleeding and abdominal pain. Take a

focused history regarding the complaint.

Personal Information:

Name……………………………………… Age………………. G……P……A……..Gestational Age………………. LMC…………… EDD…………………….

Chief Complaint:

She presented because of lower abdominal pain and vaginal bleeding. Duration?

History of presenting Illness:

Start with SOCRATES for pain details:

• Where exactly the pain? Is it in one side of the pelvis or all over.
• Onset.
• Characteristic of the pain: is it sharp, colicky…etc.
• Course of the pain: is it continues, intermittent.
• Radiation.
• Aggravating and reliving factors
• Severity.

Ask about bleeding details:

• How many times?...........is it every day? ………. How much the amount (no. of pads & fullness, make sure it is not for hygiene) any clot

or flooding? Is there fresh blood (red) or old (darker, brown) blood?

• Did she lose any tissue vaginally? This might point towards an incomplete abortion.
• Other bleeding from other places? Any ER visiting?
• Progression? For example: Spotting until 2 days ago. Now it is like a period.
• Is it provoked bleeding: Is the bleeding spontaneous or after intercourse or defecation? This could indicate a cervical origin of the

problem, e.g. infections and malignancies or even hemorrhoids.

• Did she fall? Any history of trauma?

Ask about associated symptoms:

Vaginal burning, vaginal discharge, fever

44 , pain in the lower abdomen, back, pain or burning with urination

45 .

History of the present Pregnancy:

o Type of conception is it spontaneous? or Ivf?

o Pregnancy detected by ……………. and confirmed by ……………… Number of fetuses

o Any invasive tests or procedures has been done? If yes, when? …………… why? ……………… any Cerclage?…………….

History of Previous pregnancies :

Take details of each prior pregnancy start from first to last pregnancy.

Any history if abortion? History bleeding in first trimester.

Gyne History:

o Ectopic pregnancy? Endometriosis?

o History of pelvic inflammatory disease or previous infections? ………………. When? how it was controlled?…………………

o Last Pap smear ……………..…. was it normal? ……………..…. If it was abnormal what was the management? ……………………

Sexual History:

Dyspareunia? ………… postcoital bleeding?..................

Past Medical History:

VTE, bleeding disorder, SLE, HIV, Antiphospholipid syndrome, DM,HTN.

Medication History:

Diuretics, anti-epileptic drugs, non-steroidal anti-inflammatory drugs (NSAIDs), misoprostol.

History of Early Pregnancy Bleeding

Came 4 times before

46 More common in teenagers

47 This is useful in further management as; premature rupture of membranes refers to rupture of membranes beyond 37 weeks of

gestation. Preterm premature rupture of membranes is rupture of membranes before 37 weeks’ gestation. Rupture of membranes

after or with the onset of labor is termed as spontaneous premature rupture of the membrane.

Past Surgical History:

Previous gynecological or abdominal surgery.

Family History:

History of abortions? Ectopic pregnancy?

Social History:

Illicit drugs? Alcohol? Smoking? Diet?

Discussion Questions:

• On examination the cervix was closed. What is the most likely Dx? Threatened abortion.
• How are you going to manage her? Expectant management and bed rest.
• 2 weeks later she presented complaining of loss of fetal movement. What is your most likely Dx? Missed abortion.
• How are you going to manage her then? Elective D and C.

Case: 36 week of gestational Pregnant lady presented with gush of fluid. Take a focused history regarding the complaint.

Personal Information:

Name……………………………………… Age

46 ………………. G……P……A……..Gestational Age

47 ………………. LMC…………… EDD…………………….

Chief Complaint:

She presented because of gush of fluid. Onset?

History of presenting Illness:

Ask about fluid details:

• When she noticed?.......... Spontaneous or provoked (on stress like: coughing, defecation)?
• Amount…….color………..any tissue, blood?...........odor…………

Ask about associated symptoms:

• History of Fever, Pain, malaise, smelly discharge or bleeding from vagina following rupture of membranes? (may indicate

chorioamnionitis)

• Any changed in fetal movement?
• Any contractions?
• History of fall or trauma?

History of the present Pregnancy:

• Type of conception is it spontaneous? or Ivf?
• Pregnancy detected by ……………. and confirmed by ……………… Number of fetuses …………… placenta location…………….….
• Any invasive tests or procedures has been done? (amniocentesis can induce preterm rupture of membranes)
• Does she diagnose with multiple pregnancy, polyhydramnios, malpresentation and any congenital abnormality of the fetus?
• HTN, GDM? (Can associated with premature rupture of membranes)

History of Previous pregnancies :

Take details of each prior pregnancy start from first to last pregnancy.

Any history of PROM? History of preterm delivery?

History of PROM Came 2 times before

48 If she says it’s irregular, ask here more she may say every month it gets delayed 2 days then this regular.

49 Bleeding after sex (usually she could have cervical pathology).

tocolysis causes harm. There is no clear consensus on this issue. Progesterone may be proven to be useful in

women who have had PPROM in a prior pregnancy or who currently have PPROM.

Case: This 30 year old women presented with vaginal discharge. Take a focused history from her.

Personal Information:

Name……………………………………… Age………………. Marital Status…………………. P……A……. LMC……………

Chief Complaint:

She presented because of vaginal discharge. Duration?

History of presenting Illness:

Ask about discharge details:

• When she noticed?.......... Spontaneous or provoked (on stress like: coughing, defecation)?
• Frequency…………amount……. color………. consistency…………..any blood?...........odor…………
• Relation with menstrual cycle, intercourse, contraception.
• Is after using of soaps, douching?

Ask about associated symptoms:

• Vaginal dryness, Itching, burning, dyspareunia, fever, Pelvic pain, dysmenorrhea, bleeding, pruritus, Pain on defecation.
• Red flags: PID (bleeding, lower abdominal pain, dyspareunia , sexual history)

Gyne History:

• Menstrual History: Age of menarche……… regular or irregular?......... Menstruation duration.……… Menstrual cycle

48 ……..….

Menstrual volume (no. of pads & fullness, make sure it is not for hygiene) ……………. any clot or flooding?

• Other bleeding from other places? postcoital bleeding?

49 Intermenstrual bleeding?

• Previous infections? ………………. When? how it was controlled?…………………
• Last Pap smear ……………..…. was it normal? ……………..…. If it was abnormal what was the management? ……………………

Ob history:

• Take details of each prior pregnancy start from first to last pregnancy.
• Any history of infertility? Multiparty?

Sexual History:

If the lady is sexually active ask about:

• Regular Intercourse?................ more than one partner?................Partner with STD?…………….
• Does they used any barrier (condom)?
• Dyspareunia? postcoital bleeding?

Past Medical History:

STDs, Infertility, PCOS, history of pelvic inflammatory diseases, DM, Endometritis.

Medication History:

• If any, what? ………….. why? ……………. Duration? ………………
• Use of immunosuppressant? Antibiotics?
• History of contraception. Type? …………….. duration? ……………….

Past Surgical History:

Previous gynecological or abdominal surgery.

Allergy History:

Vaccine History:

Family History:

History of Vaginal Discharge Came 1 time before

History of pelvic inflammatory diseases, PCOS

Social History:

Illicit drugs? Alcohol? Smoking? chemical irritant?

Discussion Questions:

• What is your Ddx?

o Infectious causes  Bacterial vaginosis, candidiasis, trichomonas, cervicitis

o Post-menopausal Atrophic vaginitis

o Chemical irritant

o Hormone deficiency  atrophic vaginitis

o Physiological  normal discharge

o Non vaginal abscess, urethral discharge

• Comparison between different causes of Infectious vaginal discharge:

Bacterial vaginosis Trichomonas Candidiasis

Discharge

Fishy odor, thin grayish

Especially after intercourse,

why? Semen is alkaline.

Yellow, Greenish frothy White curdy

PH ↑ 4. 5 ↑ 4. 5 ↓ 4. 5

Sign and

Symptoms

No inflammation

Inflammation: Vulvar Erythema,

strawberry cervix, dysuria, itch

Inflammation: vulvar erythema,

dysuria, itch, superficial

dyspareunia

Wet Mount Saline: clue cells Saline: motile trichomonads KOH: hyphae

Treatment Metronidazole, Clindamycin Metronidazole Azole cream, fluconazole

Case A 35 years old female complains of pain 2 days before and 3 days after her period. Take a focused history regarding the

complaint.

Personal Information:

Name……………………………………… Age………………. Marital Status………………….P……A……. LMC……………

Chief Complaint:

She presented because of 2 days before and 3 days after her period discharge. Since?

History of presenting lines:

Start with SOCRATES for pain details:

• Where exactly the pain? Is it in one side of the pelvis or all over (Unilateral or bilateral)
• Onset. (new pain or started from menarche)
• Characteristic of the pain: is it sharp, colicky…etc.
• Course of the pain: is it continues, intermittent. Does it worsen with age?
• Radiation.
• Aggravating and reliving factors (is it responsive to meds like NSAID)
• Severity.
• The relationship of the pain with her period.

Ask about associated symptoms: (ask about endometriosis, PID, Adenomyosis symptoms)

Abnormal bleeding, Dyspareunia, Infertility, fever, abdominal pressure, bloating

Gyne History:

History of Dysmenorrhea Came 1 time before