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BIMA Obstetric History Taking session recording

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Summary

This on-demand teaching session is designed for medical professionals and goes over the basics of taking an obstetric history, including common presenting complaints, key questions to ask, useful abbreviations, and how to present an obstetric history in a clinical setting. By the end of the session, participants will be more familiar and comfortable with the process of taking and presenting an obstetric history.

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Description

BIMA proudly presents the Obstetrics and Gynaecology teaching series! Join us for an amazing talk by Dr Priyanka Iyer, who will teach how to "Take an Obstetric History", perfect to receive top tips and tricks for history taking skills for exams and clinical practice.

Learning objectives

Learning Objectives:

  1. Identify and describe the key elements of an obstetric history.
  2. Demonstrate an understanding of the special elements of obstetric history as it relates to two individuals (mother and baby).
  3. Discuss common presenting complaints and differential diagnoses associated with an obstetric history.
  4. Analyze and interpret the abbreviations used in obstetrics.
  5. Practice history taking in a small group setting through case examples.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Okay when you're ready. Thank you very much. Great. Um So good evening everyone. Thank you so much for coming and for taking time out of your evening to attend the talk. Hopefully it'll be useful for you guys for, for our skis and just sort of in the future as well. So just taking general history taking um when it comes to the obstetric patient in particular. Um So just a quick introduction for myself. Um I'm Priyanka. I'm an S D one obscene Gynie trainee um in North Middlesex University Hospital. So for those of you are not familiar that sort of in North London. It's part of the North Central East London, Dina re um okay, let me change slides, done that. So this is just a little bit about myself. So I went to Kings um did it B A C in anatomy and sort of um really enjoyed my Abs and Johnny rotation actually. And then sort of platforms and Johnny and sort of over halfway through my first year. Um And it's a great specialty would recommend it to anyone considering it. Um So we'll go through some learning objectives of the talk itself. So I know that a lot of you guys have probably familiar with taking histories, know the key elements of an obstetric history. So I'm sure a lot of this talk itself is gonna be stuff that you guys have come across before. So it's gonna be more sort of laying down the foundations revision, kind of just making sure you got, have all those key elements in and a lot of it with, I think with history taking and just with our skis and also just histories in general, it's just having a format, having a set format because once you know, once you do something the same way, every single time you're not going to forget the steps, you're not going to forget the key important things. So hopefully that's what I'm going to try and kind of get across in this session. Um And we're going to try and keep it interactive. Anamika is gonna kindly help with the chat just cause I can't see what people put in the chat and I'm going to ask you a couple of questions and stuff. So just feel free to interact as a small group of us. So it should be um sort of, yeah, I just feel free to kind of interact, ask any questions that you that you have throughout. I'm happy to be interrupted in the middle. Um So learning objectives to cover the key questions that make up an obstetric history, including what questions you want to ask about the current pregnancy and any previous pregnancies because that's the only real thing that's different about an obstetric history and everything else is pretty much the same as you would ask for any other patient that you see in any other setting. Um And then the next thing is to discuss how to present an obstetric history in all ski scenarios and in daily life when you're discussing cases with senior colleagues. Um and the last bit, we've got sort of 34 cases actually where we will hopefully be able to demonstrate some history, taking skills to upset your case examples. Okay, so here's your first question. So tell me what is special about an obstetric history. Just tell me anything that you can kind of comes to your mind when you think about an obstetric history, it could be anything at all. What's like the first thing that you think of. So feel free to answer any questions in the chat or if you want to mute as well, you're welcome to do so. So it's an option. Yeah, it's a very open question. But yeah, it's just anything. What, what is special about an obstetric history, I'll start it. But I think we have some people that are contributing the chat. So I guess one element is um in obstetric history, technically have two individuals um compared to one in a normal medical history. Oh, yes. And someone in the chat also said the thing. So you extricating for um the Byetta slush baby and the mother as well. Yeah. Yeah, that's a very good point actually. And that's something that you kind of have to keep in mind. So you kind of want to ask about questions to do with the fetus and questions to do with the mom. And that's also just a very good thing to think about with like any obstetric condition. So you want to think about like, how does that affect the mom and how does that affect the affect the baby? So, yeah, that, that's a really good point. That's a good place to start actually. Um So this is just to show that this is how you might feel at the very start of this, talk about obstetric history. And hopefully by the end, I'll kind of instill the, you know, the key things, the key tips and you'll kind of be feeling a bit more relaxed with no fear. Um So presenting complaints, what are the common, presenting complaints that you would come across in maternity triage? So triage is um just for those who might not have done an upset trick placement. So triage is we have women come from 18 weeks onwards, before 18 weeks, they present to a any. So from 18 weeks onwards, what kind of things do we commonly come across in triage? You can shout type a few things or you can type in the in the chart books. Okay. So you have some comments coming through in the chat. We have bleeding. Hmm. Yeah. Reduced fetal movements. Yes, we see that a lot. Yes. Abdominal pain. Uh, and P V bleeding. Yeah. Great. Anything else? Some more people contributing, just give them some time to type. Okay. We have headaches. Yeah. Definitely something. I've seen Peritus query, colitis. Uh, college stasis. Right. Yeah. Diabetes. Yeah. I mean, less likely some, sometimes you might get someone who's kind of, who has been referred from the diabetes. Like they've got like very, very high sugars and you're concerned they might have like DKA or something. Yes, that could be something that they come in with, I suppose in line with that. But also say nausea, vomiting. Yeah. Nausea, vomiting. Great. Yeah, that's something as well. A bit more. We kind of sympathy that a lot more in the early pregnancy unit. So, with like hyperemesis and stuff and it usually kind of tends to settle down. But you, do you still see it? You still see it a bit later on as well. Yeah. Anything else? Um, kind of thinking about the other photo as well on the, um, the photo on the right? Because we also see women up to six weeks postpartum. So, what other things do you think they would come in with Jaundice? Jaundice? Um, you mean in the baby, baby? Yeah. Oh, so we, we don't, we wouldn't see babies in triage it would just be the mom's. So, I don't actually know where, uh, where do the babies go ahead actually, you know, uh, they, they would go to anything. Ok. So they'll be in the children's any neonatal team. Yeah, the neonatal team would see them. Yes, it would be. It would be through. And I don't think they've got, like, a way of bypassing and, you know, they'd go, they'd go into and I think, and they would go straight to the pizza, the neonatal team. Yeah. It would be depression, like the kind of symptoms. Blue baby blues, depression, put that kind of, yeah. Possibly. Yeah, that could, that could be something that could come in. Uh, got it quite a few more in the chat coming through. So we have feeding concerns. Okay. So, again, PND postnatal depression, psychosis, postpartum hemorrhage or PD reading. Yes. Um, breastfeeding problems and query breast abscess. Yeah, that's a very good one as well. Yeah. Um, and there's something we've been seeing a lot of recently, we've been seeing loads of wound infections actually. I mean, like, that might just be something that's like in my unit, in particular. But loads of women coming in with like bruising from the wound or like the wound separating or like just a wound being red hot to touch. So, we've been seeing a lot of wound infections, actually, a lot of like collections and stuff post operatively. I don't know. That's a, necessarily a good thing. But um yeah, so we see a lot of so yeah, we see wound wounds, postpartum bleeding, postnatally, a lot of the breastfeeding concerns. So they would be seen by the community midwife. Um But yeah, so then that could also possibly come in as well, but that would usually be dealt with the midwife. The obstetric team would less like less commonly be involved in things like that. Again, breast app says moustache is that sort of stuff as well. So one really good thing that would be useful when you guys are revising and stuff for our skis is to kind of think about what the common presenting complaints are and what the common differential diagnosis is because then that kind of, first of what it guides your history taking, you kind of know what sort of questions to ask. Um And it also allows you to kind of think about differentials at the very end because when you're presenting back in a Noski setting, most commonly, you would sort of present the history and then you'd say my top three differentials, usually in Kings, they would say just give us three differentials, but you know, you don't have to give three, you can just say my top differentials, our X and Y or you can just say this is my top differential, but they like you to give kind of like more than one. But so if you've got like a list of presenting companies and you kind of know already. So postpartum hemorrhage, you're thinking um you know, if, if it's, if it's not initial, if it's kind of like delayed, um you're thinking it could be like endometritis, it could be retained products, it could be, you know, you're just trying to think like what, what else could it be? Um Essentially. Um Yeah, so that's, that's just something to kind of think about. Just have a think about all the common presenting complaint and what the differential diagnosis is. Um So just quickly about abbreviations, um you can just go through these quickly just cause there's loads of abbreviations in obs and janie actually. And this is kind of a bit more for like when you're on your placement and stuff, but it's just useful to go through. So what's SVD? Some people are typing in the chat all week and I'm to respond. Anyone want to try you get a spontaneous vaginal delivery. Yes, lovely. Um E M C s and es yes, we'll do them together just for um just make it easier. Uh First E M C S S elective C section and then uh I am his emergency and E L is elected. Yeah, perfect. Um And I a Well, induction of labor, perfect P prom. Just give me a few minutes for people to take. I mean, yeah, it is quite a long um understandably abbreviated preterm, pre labor rupture of membranes. Lovely and F D which I always just, yeah, and I don't see why you have to shorten it. But anyway, uh fetal death. So it's forceps delivery for fetal that you probably say intrau try and death. IUD. But then it, then it solves the same as intrauterine device. So I don't think that IUD is a very good acronym, but in an obstetric sense, IUD is intrauterine death and FDS forceps delivery. But it's like less commonly used. I haven't seen fetal death being put down as F D. Usually they put IUD. Um But yeah, I'm happy to be corrected on that. Um E D D is a bit easier. Estimated date of delivery. Lovely and E F W estimated fetal weight. Amazing. Uh I think this is the last one A F I amniotic fluid in dec lovely. Um fine. So the next thing we're going to sort of cover before we go to the obstetric history itself is gravity versus parity. Um So what is the difference between the two? Does someone want to someone the next name or grab? Grab? Gravity is gravity? I meant to say gravidity that's missing like a D and, and I, but yeah. Oh, oops, that's sorry. Okay. Fine. Gravity is a total number of pregnancies regardless of the outcome. So what is parity? Let's, let's let's do how many Children she had? Um Yes. What about if someone has had a stillbirth at 27 weeks? Does that count as a parity? So, you've got some comments in the chat. So gravity is number of times pregnant parity for number of birds. Another one saying parity is number of birds passed 24 weeks. Hmm. Yeah. So it's actually the second. So it's the number of pregnancies carried out, carried over the threshold of viability, which is 24 plus zero in the UK. So that's just kind of stress the point that if you've kind of um had a delivery past 24 weeks, that then counts as um a point towards your parity. So we'll do some examples. So a patient is currently 26 weeks pregnant already has two Children of her own. She reports having a miscarriage previously at 10 weeks and is still birth of 28 weeks. So what would her gravidity and parity be? You think one response with para four plus one and grow vertically? Five, another is uh seven weeks and that chances coming through. But uh a bit more consensus of gravity 85 powerful uh one response with a probably three para two. Okay. Um Yeah. So then, so let's count the gravidity first. That's the easier one. That's every pregnancy, right? So she's currently pregnant. That's one, she's already got two Children of her own. So that's three. She's had a miscarriage that's four and it's still birth, which is five, right? So she's Gravida five. Yep. And her parity is how many pregnancies she's carried over the threshold of viability. So, a parity is she's had two Children. They were born over the threshold viability. That's two and then another stillbirth 28 weeks, that's three plus one. So the plus one is how many losses you've had? Whether that's a miscarriage or a terminations or an ectopic, that's all just plus. So she would be Gravida five para. What did we say? Three plus one? Does that sort of make sense? We'll carry on. We'll do two more examples. And then we can kind of, we can ask any questions if you have after. So patient's currently pregnant, she's had one previous delivery and one previous miscarriage. Sorry, we just had a question regarding the gravity party for the previous element. Um So would the current pregnancy not count uh as it's greater than, so it's greater than the 24 weeks is 26 weeks? Yes. Ok. So because she's not, she hasn't delivered it yet. So it's deliveries. So it's because she hasn't delivered that baby yet. That, that counts as a gravidity and not as a parity yet. Does that make sense? Once she delivers the baby? Then it would, then she would be uh Gravida five Para should be then or wouldn't she four plus one? Yeah. Yeah. So the reason why it only counts for the gravity and other parties because she hasn't delivered that be be she's still currently pregnant. Okay. So responses for the second question, we've got gravity three para one plus one. Any others, I'm just waiting for them to take, get some people taping. Okay. Do you think that was the only response at the moment for this one? Great. Yes, that's correct. So, it's currently she issues had three pregnancies in total. She has had one previous delivery and one previous miscarriage. So that would be Gravida three para one plus one. So patient is not pregnant at the moment. She's had a twin pregnancy resulting in two live buds. This one's a little bit more confusing and different people kind of say different things. But what have you, what have you guys been told about twin pregnancies and parity? Just give it a few minutes for people to take. Okay. Uh So we have one option saying grabbed a one power to another option saying Gravida one para one. Yeah, so I've seen both but I think from what I've got from looking around, it looks like technically a twin pregnancy should count as one for the parity. Um but some people like some people still say it's power to but it should technically be one. So to the last one would be covered at one parallel. Any questions about uh I should really, I'll change those slides and we send them around any questions about gravity and parity. Yeah, you can feel free to ask me questions about the late one if anything comes up or if you think of anything. Um Okay, let me how do I change? Okay, thank you. So, now we're gonna go through the obstetric history itself and I sort of split it up into sections just so you kind of have a framework of uh kind of what sort of questions to ask as you go along in the history taking. So you kind of start off with any history presenting complaint. Um You kind of want to ask all those questions you, you that you usually would anyway, if someone comes in with pain and someone comes in with bleeding, um all the Elect Socrates questions ask, you know, bit more focused specific closed questions. Um trying to understand how long it's going on for. When did it start? What makes it better, what makes it worse? So all those usual usual questions that you guys are quite comfortable asking by sort of by this stage of your training. Next one is questions about their current pregnancy and we'll go through exactly what questions you need to ask. The next bit is questions about the previous pregnancies, two previous obstetric, and you want to also ask about the previous gynecological history as well. For example, if someone has had um spotting in pregnancy, you also want to ask about the previous smear test as well as previous smear history because that is important. You want to ask about the previous um history of any sexually transmitted infections, previous P I D. That sort of stuff. That's why got any history is important. If someone comes in with, let's say, um left side and lower abdominal pain, you do want to know. Do they have a massive cyst? Um, do they have a history of anything like that? So that's why all the guy, any history and stuff is important. Oh, sorry. And these are just uh sort of a standard history taking questions. So, past medical history, past surgical history, social history, family history. So you passed this medical history is important. You want to know if someone has got back one of the epilepsy, uh diabetes, high BP, all of those things, past surgical history you want to know about. Um, but they've had like a previous midline laparotomy, for example, that would be important to know, especially if you're kind of um you know, if you're doing, you're planning for your Cesarean section, that sort of stuff obvious someone's had a previous Cesarean section that's important to know social history is important to know. Uh family history is also quite important to know as well. You want to know if someone's, you know, taking drugs, if they're taking, um they're drinking alcohol, they're smoking. All those things are important in the pregnancy and family history is that they have a family history of any diabetes, high BP, those kind of things. Um then drug history and drug allergies as you would for like any other history and ideas, concerns and expectations. I've kind of added that in, especially if you don't usually tend to ask that in sort of real life. I don't, I don't kind of ask women in triage. So, what are you concerned about? What are your expectations? What are your ideas about what this could be? I do ask them what they're concerned about more often, actually. Uh, I think it is quite important to kind of know exactly what it is that they're really, really worried about. So you can address that, the ideas and expectations less often. But I think they do like it, it kind of gives you those bonus points, you're, you're, you know, bonus points from the patient and also kind of just shows you to be like a bit more of like a holistic clinician. So it's always good to kind of add that. And at the end, um they kind of drilled that into us and Kings, they were like, you need to ice the patient ideas, concerns expectations. Yeah, that's just something to kind of add in at the end. Uh may have done that, sorry uh with the ice sometimes rather than doing it as a sort of a shoehorned element just in the uh you can also integrate it within the history itself. So after the presenting complaint, is there anything in particular that they think might be going on, might be a good way to get them into the conversation and then the concerns make them up within that or in the H P C section. So you can find out with the flow like where you feel it's comfortable and more practice. You do the more smooth it gets definitely integrate all three because they do count as points in your Yassky exams. But just in general in life, your patient's will like you more. Yeah. Yeah, I know for sure. Actually, that's a very good point like you can, yeah, I think you kind of um you develop like a way of asking certain questions. Um and also just kind of fitting these questions in. So yeah, that's a really good point actually. Um And yeah, definitely something to kind of practice, especially when you're kind of practicing and you're asking groups and stuff. Um So questions about current pregnancy, what kind of questions would you ask about? What do you want to know if you agree to type or a mute? That's absolutely fine. Okay. So we've got some questions coming to you. So we have the pedal movement. Yeah. Gan's uh how far along are they in the pregnancy? Yes. Gestation. Yeah. Okay. You are just coming. I'll just give it a few minutes. Uh So is it planned or unplanned pregnancy? Uh They're using folic acid uh up to date on the scams, gestation, number of episodes of presenting complaint. Um I think, see uh sorry, I'm not your pregnancy sx. Could you just elaborate on that? Sorry. Oh, you mean pregnancy symptoms? Uh possibly. Yes, sorry abbreviation that we got pregnancy symptoms, um thickness, nausea and breast tenderness. Okay, great. Um Anything else? I think a couple more inches typing coming here? Okay. Uh Any issues raised in any of the previous appointment such as urine dipstick or BP? Okay, great. Um Yeah, so all those things have really good questions and, and then they're all questions that you need to ask, um especially about their sort of current pregnancy. So we'll kind of go through all of them kind of um in order. So you want the first thing you want to know is how far along the pregnancy are they? Because it very much kind of really changes your differential diagnosis and also changes kind of your management as well. If someone is, let's say presenting with uh P V bleeding kind of at 20 weeks versus that they're coming in at like 36 37 38 weeks. It does change it, it kind of changes your differentials a little bit. It kind of changes the way that you would approach those cases. The gestation is very important. That's the first thing that you want to establish. Next thing you want to establish is if it's whether it's a singleton or a multiple pregnancy. So you want to know, right? Is it, are you having a singleton or a multiple pregnancy and usually kind of get that information very quickly from the book, from their maternity book. Um next thing is, is it a spontaneous conception or is it an IVF pregnancy? Do you want to know that as well? Um After that, you want to know about the last scan. So things that you kind of the information that you can gather from a scan is presentation. Presentation is a bit more important a bit later on pregnancy. I mean, if they're breech at like 20 on the on the growth scan, I mean, that's really baby is going to turn around. It's not not super significant, but presentation is important that catholic is a breach, estimated fetal weight. So how well grown as the baby A F I? How is how how well is how much is the liquid around the baby Doppler is the blood flow to the baby and the placental site, is it low lying placenta? Is the placenta, posterior, high, anterior high? So all of those things are important as well. So what was their last? And you can have a look at their scan report. In reality, you kind of have a look at the scan reports, see all of those measurements and stuff. How many scan? Just out of curiosity, uh a low risk woman with no risk factors, right? Nothing at all. How many scans would she have in her pregnancy? Okay. So a couple of different options with one once in one and one thing too. So it's actually too because you've had, you have, you will have your dating scan, which is at the very beginning. So between 11 to 13 weeks, you have your nuchal translucency scam. That's when they will do the testing for the Down Syndrome as well. So that's the first thing you'll have. And the next scan that you have is your anomaly scan, which is a 20 week scan. And if you've got any risk factors, for example, high B M I women by like doing this inf ASIO fondle height is not going to be as accurate. Anyone who's got a previous baby whose small doesn't increase risk of having another baby that's small for gestational age or S G A, then you, you, you put them. So if they have any risk factors and they have, they have cereal growth scans should be every four weeks, 24 weeks, 28 weeks, 32 weeks, 36 weeks. Those are, you can kind of do them every four weeks. You might do them more frequently with any other issues. So you want to know what the last scan was, any issue with their previous scans and you want to check the anomaly scan as well. See if there's anything picked up on the anomaly scan. Um Then you also want to know if they've had any medical problems during pregnancy. And specifically, you want to ask about things like preeclampsia, any diabetes issues and you have such a college stasis, any of those issues during pregnancy. You also want to ask when they last have their blood test? Any issues with their blood test? You want to ask about blood group as well? Are the recess positive or their recess negative? You want to ask about their booking bloods? So do you guys know what diseases do we test for on your booking? Bloods? What are the main ones? Okay. So a couple of options coming S T I HIV HEP B syphilis uh Downs Edwards Patel uh HIV thalassemia. Um Yeah, so it's August is the main, in fact, um I should have said infectious diseases, the infectious disease that we test for is HIV happy and cephalous. They use the test for rube uh I mean, not infection but they used to, they used to, it is infectious. Are they use test for rubella but they don't test for it anymore. Um And what else was I going to say? Um You also test for thalassemia as well. So like when you do your blood, when you kind of do your blood group and stuff, it'll kind of tell you if they're sort of like an e maker, if they've got like a microcytic, an email will tell you like if there's a chance that they could have a thalassemia and stuff. Um So you kind of look for that as well. ST I you don't routinely test for it. But if someone has like um let's say discharge or anything that you can, you, you, they might have like swab sent in triage basically. Yeah. So the main kind of infectious diseases that you test for HIV have been syphilis. So rubella is not tested for anymore. So you can look at the book booking bloods and you can check for their serology um and then just check their blood group and all of those things as well. So these are all the questions you want to ask about the current pregnancy. So how far along singleton or multiple spontaneous conception is the IVF conception? Any medical problems during the pregnancy and any issues with their previous scans? When was the last scan, then check their blood's as well. Those are all the questions about the current pregnancy. So you want to ask about obstetric specific symptoms as well. So you want to ask about these other things you guys have mentioned already. So abdominal pain, vaginal loss. So you asked about bleeding, you ask about discharge and you ask for a rupture of membranes as well. So kind of a sudden gush of clear fluid uh reduce fetal movements. Very important. It's very common presenting complaint that we see. Um you ask about headaches. So you ask about preeclampsia symptoms. So, headaches, epigastric pain, peripheral edema, visual disturbances, you ask about itching. So if you think about a trick called stasis, you asked about peace symptoms or chest pain, shortness of breath, unilateral leg swelling. Um then you ask about just general mental health as Well, it's always important to screen for things like self harm, suicide is relevant. Um Yes, those are kind of the main things that you think. So everyone. So if you ask the abdominal pain, vaginal loss, reduced fetal movements and think about these kind of um condition specific symptoms and you can ask, ask about those as well. So the conditions we sort of want to screen about screen for. So in every kind of every contact, whether it's Anthony clinic or triage, things like preeclampsia. Oh, see pe symptoms. And again, like I said, mental health as well is important to kind of ask for um any questions about that. So I guess there was a question for perhaps a previous area, but why do we ask for blood group and the uh booking blood test? Yeah. So then blood group is important because if you've got someone that comes in with an antepartum hemorrhage, let's say, and their recess negative, then you want to give them anti D. So that's why you'd ask them for that. Serology is important. Um a bit, I mean, maybe like it's a bit more sort of an antenatal clinic if anything. Because if you're thinking about kind of mode of delivery, let's say if someone's HIV positive and you think you're more of delivery, not that they can't have a vaginal. Every, it just depends on what their viral load is. And you know, they're taking antiretroviral therapy and stuff like that if they've got syphilis, that sort of stuff. So it's kind of a bit more in an think clinic than, instead of triage so to speak. But it is just something to think about as well. It's kind of just get the general picture, but it's less so kind of in an office key setting. You wouldn't necessarily ask about serology and stuff in our ski setting. It's a bit more kind of in real life. If you were to say that such a patient, you kind of have those um you'd have all that information in front of you. And also often women don't really know those you don't remember like, oh, I have those blood tests. I think they were all normal. So you kind of go that's a bit more like going and logging into the system and checking all those things if that makes sense. But you can just ask them if they've had any blood tests in pregnancy where they normal and that sort of sorry. He's asking general questions. Any other questions? Not at the moment? Okay. So previous etcetera history, what do you want to know about their previous pregnancies? Please feel better on mute or type in the chat. Okay. So we have a mode of delivery, miscarriages, any stillbirths, ectopic or molar pregnancies. How many Children and we took delivery and any complications? Perfect. Yeah, that's pretty much everything. So um let's go through what if the number of pregnancies um number of terminations, the top of pregnancies, miscarriages you guys have mentioned already 20 days conception of IVF previous more delivery, very, very important. Any complications in previous pregnancies, you guys kind of have covered sort of everything already. See exactly as you guys said, those are all the questions that you kind of want to know about previous, about their previous pregnancies. Because also anything that has happened as a as a very, very blank of rule, general rule of thumb, anything that has happened in a previous pregnancy, there's an increased risk in the next pregnancy. Obviously, there's an increased risk in next pregnancy. Um Gestation, diabetes is an increased risk in the next pregnancy, preeclampsia. There's an increased risk. So you want to know what their previous obstetric history is. Um that kind of gives you an idea of their risk in the next pregnancy. Okay, additional points that are similar to other histories, which we've kind of gone through already in the schematic diagram that I showed you. So Gynie history, past medical, past surgical, regular medications, drug history, social history, family history, and then I switch you kind of adding as you go along. Um tiny history. What kind of questions do you guys asked specifically? This is not a Gynie history taking session, but what kind of questions would you guys ask in a Gynie history? I kind of mentioned a few things already at the start. So you can uh yeah, so we have some responses, we have pain discharge, bleeding, smears menstrual cycle and into Syria and a history of gynecological problems such as speakers. Mhm. Anything else? No further response of no, sorry, any abdominal pelvic pain good and uh sexual history as well is very important. So ask about uh any previous history of S T I S history of P I D, those kind of things as well as important. Um And with bleeding, you want to ask about uh postcoital bleeding, intermenstrual bleeding, heavy, heavy, heavy periods, that sort of stuff as well. Okay, any questions about kind of history taking and kind of gathering all of that information. And this picture is just to say that this is something that sort of happens all the time where you kind of, you've got an agenda in your head of getting through your history, asking all of your questions and then the patient kind of comes up and they've got their own agenda and it's kind of like both of you kind of trying to kind of meet in the middle, so to speak and often sometimes it's about giving them that like first minute to kind of just get their presenting complaint out. And often you can get a lot of information actually in that first minute. And yeah, it's, I mean, a lot of it's just practice and you guys have probably like practice loads of history taking and stuff by now, but it's just kind of it is difficult to kind of because especially in an abs and any history, there's so many questions that you need to ask and the worry is always am I going to be able to finish on time? But again, it's just making it very slick asking those kind of questions. Um It's not about combining loads of questions into one statement. It's about asking short questions just that are just kind of covering one point, but it's about being kind of quick and systematic with it, but that just comes with practice. Yes, I have a question history taking. Should we ask about the due date? Um I, so the only reason why I don't necessarily ask is because I have that information already in their maternity notes. But yes, you can ask. I mean, I, I would, yeah, you, you can, I think there's not no harm in asking. Um But often you kind of reality. You have that already. Yeah, they've been important to bear in mind sort of how far along whether or not they've had any scans and things which hopefully they'll provide in some stem but not everyone may know their day date. So just obviously uh spare that mind that that's a good question. Um Yeah, but a lot of people will know how many weeks pregnant there's, that should kind of give you an idea. Lovely. Um Fine. So key tips on presenting a history. So you kind of wanna when you're presenting a history of things that you want to kind of keep in mind as you, you want to kind of stay, you wanna give sort of like short, send shortish sentences with not too much like PFAFF around. So you kind of, you've got a lot of information gathering that's happening from your history and your kind of condensing it to a couple of sentences. You kind of want to have a few key things. So you want to say how old the patient is? So I've got 21 year old lady who is gravity. Uh one para zero, you can just issues prime it. Uh She's come in at 20 weeks, your station with um let's say she's coming with some Peavy bleeding. You want to give relevant positive and relevant negative findings. So what is relevant, negative findings? She's got no abdominal pain, she's not got any kind of um any fever symptoms, anything like that, relevant positive symptoms you want, you want to say as well? So anything that's kind of um so this happened after sexual intercourse. She's had this before. She's had previous. Um another important negative finding would be kind of if they've got uh previous history of negative cervical smears, uh previous history of normal cervical smears. Sorry, that's an important negative finding, for example, or they've got like a history uh no previous history of sci that's an important negative finding and what, what your differential diagnosis. So my top three differential diagnosis is X Y and Z that's kind of like how you would present to history. So age riveted that again as well. That wrong bag lividity and parity gestation presenting complain relevant positives and negatives and differential diagnosis. And often they would kind of ask you what you would do now next as well. So I kind of divide the next steps into bedside bloods and investigations. It's just kind of like make sense in my head. So what can you do by the bedside? You can examine your patient. You can do a C T G for the to check the fetal well being or you can just listen in as well. Um If they're a bit later on in their pregnancy, you can do a C T G, um, to check the baby, you can do urine dip on the bedside. You can do a full set of observations that you can do it on the bedside as well. You can do bloods. Um, so what blood you would send off and why is quite important as well and that investigation. So that's what other investigations would you do? For example, would you, um, you know, would you do a CT P on this lady? Would you do a VQ scan? You know, are there any, is there any imaging that you would order specifically for this patient? And then what, what your plan would be next year? Discuss with the senior discharge? I went to Labor Ward, that kind of thing. Those would kind of be your next steps. So if you kind of think bedside bloods and investigations, that kind of like, makes sense in my head and that just make sure that I cover everything, um, that needs to be covered. Um, yeah, those are just key tips when you're presenting a history. Um, and it kind of, again, just takes a lot of practice and a lot of it's just kind of condensing everything. And the thing that kind of really helped me when I was doing or skis and stuff is just kind of taking a step back and actually kind of forming those thoughts and forming those sentences in your head before you present. You don't get any extra points for kind of presenting the history straight after you've taken it. Actually, it's much better if you kind of take that time to kind of collect your thoughts, collect all that information together and then come back with something that's a bit more coherent. Um Yeah, that's just like a tip when it comes to kind of presenting histories. And he said, I mean, that's, that's probably things that you kind of knew already. But the top thing is just remember to kind of mention age lividity and parity and gestation as well. That's just kind of additional things to kind of start off. Have you just had a question in the chat um asking what are some of the main common conditions or presentations that they should read about before their placement starts? Okay. So before your placement starts. So I think you kind of want to know, uh, we want to know what the regular antenatal schedule is. So it's like a really good guy on like antenatal care. So you kind of want to know exactly what women get during their pregnancy. So, what kind of scans they have, what bloods they have, how frequently they get seen in the Antenatal clinic. That's just kind of a general overview. Things that you definitely want to read about our BP because he loads of patients with high blood preeclampsia. Read up about diabetes as well. That's another common thing that we see and then read up about labor. So kind of like what the different stages of labor are, that sort of stuff that's kind of like the obstetric kind of side of it and the guy, any side is kind of separate. Um, yeah, so Gynie also, you kind of want to read about like all of your acute Gynie things, like bleeding, all of those things as well to, um, and what else do you want to read about with obstetrics? Um, yeah, those are kind of your common things that you kind of come across, um, that you should probably like read up about before you kind of start your place. I'm sure there'll be loads more that you'll kind of come across and want to read up about. It's, it's a, it's a very, very vast specialty and it's very, it's so different to anything else in medicine. So, like, don't be worried if you kind of feel like a bit overwhelmed with this type. I think it's, the more you read up about it, the more you kind of familiarize yourself with it kind of gets a bit easier. Any other questions? What's at the moment? Okay. So, uh this is just kind of like a recap slide. So, yeah, so you've got your presenting complaint, ask all the questions about the presenting complaint, ask about the current pregnancy and the current pregnancy symptoms as well. Ask about the previous obstetric and gynecological history. Then you go onto past medical history, past surgical history, social history, family history, then ask about drugs, both what drugs they're taking, what drugs they were taking before pregnancy. So for example, if someone with poorly controlled epilepsy was taking, um let's say lamoTRIgine before pregnancy, they completely stopped, that's something to know about. So you want to know what they were taking before pregnancy, what they're taking at the moment. Um They're, they're allergic to any medications and then ice as well. And as Anamika sort of pointed out, so you can kind of put that in alongside the history as you're going along just to kind of help with the flow and also just help with report as well with the patient. Okay. Fine. So we're gonna do, we've got four cases. Uh, two of them I think are antenatal cases and two of them are postnatal cases. Um I'm just going to get my phone just cause I've got the case is kind of written up on my phone. Um Okay, let's start with this. We've got a 30 year old lady, she is 32 weeks pregnant, she's attending triage with constant lower abdominal pain. Um So you guys, so we can either have one if mean of one, if you've got one brave person that's happy to kind of step forward and want to do the whole history, we can do it that way or you guys can put questions on the group and then I'll answer those questions as we go along and I'll be the patient basically in this case. So it's kind of like a mock a second. Yeah, like a mock patient. Essentially. Anyone brave enough to do the history taking. Yeah, he'll be to volunteer and, and meat. Yeah, there's a small group of us. So it's time. It's all right. It's a pretty, I can't have a go Oh Amazing, great. Uh Sorry, I can't see who's speaking and said, what, what's your, what's your name? Uh Lahar. Okay. Um Great. So Lahar, um you can kind of treat it as, as an Noski scenario so you can kind of come and introduce yourself, do other things that you usually would. Um Okay. Um So my name is Har I third year medical student. Um I'm just here to watch out with you before you see the doctor. Um, does that sound okay? Yeah, that's absolutely fine. Okay. Can I just confirm your full name into to birth before you begin, please? Yeah. So my name is Reminding Bianca already to birth. 19th February 1995 90 90. Yeah, let's say 1990 it's actually not 30 anymore. Yeah, 1993. You would be, wouldn't. Yeah. Okay. And what's for you in today? So I've just got really bad, um, lower abdominal pain. Um, it's kind of just, just, just around here sort of in the center really. Um, it's been going on for the last few hours. Okay. And did this come on suddenly? Um, yeah, it came on suddenly and it's sort of, um, it's been coming and going. I'd say. So. You said it's central? Is it like the lower part of your abdomen? Yes. So the right at the bottom. Yeah. Okay. And, and can you describe the character of the pain to me, please? Um Yeah, so initially was sort of, it started suddenly and it's, um, it sort of, it was coming and going now it's a bit more constant. It's, I'd say it's sharp pain and um, is it, is this pain radiating, moving anywhere else? Um Yeah, some of the pain is going down my legs and it's also kind of spreading around to the back as well? Okay. Um, uh, does anything make the pain better? Not really, it's, um, I try taking some paracetamol but hasn't really helped with the pain. And, um, you said it's been going on about, since this morning? Uh, yeah, so a few hours. Yeah. Yeah. Few hours. Yeah. Okay. Um, and does anything make the pain worse as well? No, not really. Okay. And how would you score the pain to be from Missouri to 10 scale and $10 pain. It's pretty, it's pretty bad. I think it's sort of like when it started it was sort of like a five and it's gonna become an eight now. Okay. Um, okay. So you're, you're pregnant, um, and have you ever experienced anything like this before during your pregnancy? Um, I said I've got just like regular, you know, when you just get pains and pregnancy just kind of like a bit like twitches here and there and I've kind of been getting a few, kind of, um, not, not regular contractions or anything. I just like back to Pakistan Hicks, I think. Um, she had like with my previous pregnancy. Um, but yeah, it's not, nothing like this basically. And, and you never experienced any symptoms similar to this in your previous pregnancies either. No. No, not really. Okay. Um, can I just, um, confirm, um, so how many pregnancies have you had before? So, this is my second pregnancy. I've had one pregnancy before. Before. Okay. Um, and have you ever, have you had any complications during this pregnancy at all? Um, yes, I was diagnosed with preeclampsia at, uh, around sort of 25 26 weeks. Um, because I did just, they, they saw some sort of protein in my urine and my BP was a bit high as well. So I'm taking medications for that. Okay. Um, and do you know which medications they're taking? Well, uh, yeah, so I take the labetalol and I've been started on a fetid pain as well. Okay. Um, all right. Um, okay. Um, so you're 32 weeks into pregnancy for this, um, pregnancy. Um, is this, um, single, do you know if this is a single baby or do you have multiple? No, just the one, just, just one baby? Okay. Um, and was this a spontaneous conception or did you, um, uh, yeah. No, no, be the news idea if it was just, um, yeah. Okay. Uh, and, um, have you had your, all your scans regularly? Uh, yeah. So I had, um, I had my initial scan then I had the growth, the, the anomaly scan, sorry, was all fine. And they've been monitoring the growth of the baby and checking the blood flow to the baby as well and that's all been fine. Actually, they've been doing that every four weeks. Um, so I just had my scan this morning and that was fine. Okay. Um, and so, okay. Um, have you had like, any, did you have blood tests or anything that's come up to normal or any issues with your blood tests? Um, no, they, they found that I was anemic or one of my blood tests and then I've just been taking iron tablets. Okay. But that's it. There's nothing else. Okay. And, um, do you know if they checked your recess status? Um, yeah. So my blood groups or positive? Okay. That's fine. Um, so with this abdominal pain, have you noticed any other symptoms, like nausea or vomiting? I am feeling a bit nauseous because of how severe the pain is, but I haven't had any vomiting. Okay. Uh, and have you noticed any bleeding? Um, yeah, I mean, you mentioned actually I did have a little bit of like fresh red blood actually. Okay. Was this movement? Was it today that you saw that? Yeah. Yeah. Yeah. Today and it's the first time you've, uh, noticed bleeding. So I had some bleeding at the very beginning of my pregnancy, sort of like a few weeks in but nothing since this is the first time. Yeah, this late in pregnancy. Yeah. Okay. Um, are you, how much have you been bleeding? So, I mean, it was, it's probably a bit more kind of spotting. If anything else, it's not like it's clots or anything. It's kind of like, yeah, it's not, not a lot have been needed to use pads. No. No, not like it's like it's not even like it's a few spots on the pad. Okay. Okay. Um, that's fine. Um, have you noticed any, like other discharge? Um, no, no discharge. No. Okay. Um, and have you, uh, are you still feeling fetal movements as normal? Um, so my baby, I mean, I do feel like my, my baby is moving a bit less today than, than he usually is. Okay. Um, yeah, so probably apparent necklace actually. Okay. Um, um, have you noticed any, um, like any chest pain, any shortness of breath? Um, no, no chest pain, no shortness of breath? Ok. That's fine. Um, I'll just ask you a few questions about your previous pregnancy. So many pregnancies have you had before? Yeah. So this is my second pregnancy. So, one previous pregnancy. Okay. And, um, what's that? Um, also spontaneous? Uh, yeah, that was just natural. Yeah. Yeah. And how was the delivery of that? Um, so I delivered it, it was, it was a normal delivery, normal delivery and it was the baby born pre full time. Yes. Okay. And whether any complications during that pregnancy or during, uh, labor or after. Um, so I had, I think I did, I had preeclampsia on that pregnancy as well. Yeah. Ok. Um, and I was a baby fine to breath and complications. No, no baby was all good. Okay. Um, have you, um, ever been diagnosed with like any S T I S, um, pelvic inflammatory diseases? Do you know? Um, no, no, no, I haven't. Okay. What's, what's pelvic inflammatory disease? Um, um, is it like, um, chlamydia and? Oh, okay. That's what you meant to find. Um, um, no, no, not that I know. No, I've had a few sts screens and stuff and they've been linked. Okay. Um, you have done okay. Um, do you have like, any other medical conditions of the, um, and like any chronic medical conditions? Anything you see the doctor regularly for? No, no, nothing. Um, have you, did you have like, have you ever been diagnosed with diabetes? Um, have you ever had like any previous surgeries? No, no previous surgeries? Okay. And, um, can I just ask what your, what's your occupation? Um, I am a teacher. Okay. Um, and, um, are you still working? Uh, no, no, not working. Okay. Um, is this, um, pain affect, how much is this been affecting you, like your life? Um, I mean, I think I'm just a bit worried just because of the, like the bleeding and the pain and stuff. I think that's kind of worrying me a little. I mean, I'm, I'm quite concerned and I'm just worried about my baby really more than anything else just because babies also not moving. So I'm just kind of, yeah, so I think all of those things kind of combined is making me sort of quite anxious actually. Was there anything in particular that you were thinking about? Um, No, I mean, I just, yeah, I mean, I'm just worried, I kind of haven't really thought, um, by anything kind of further than that. Okay. Yeah. Um, and just a few questions you have to ask everyone. Um, do you, do you smoke at all or have you ever smoked in the past? Um, no. Okay. And do you drink alcohol or have you ever drank in the past? Very occasionally in the past? And I don't drink no more. Drinking, drinking, drinking enough. Okay. And have you ever used recreational drugs or do you use recreational drugs? Um, no. Okay. And, um, are there any medical conditions that one in the family? Um, not that I know. Okay. And, um, so you told me you're currently on labetalol? Uh, Nifedical. Are you on any other medications? So I take iron tablets as well for the anemia. Um, and I want aspirin as well. Okay. Um, and, um, do you have any allergies that you know, of two drugs or anything else? No. Okay. And, um, okay. Um, thank you for talking to me. Um, my question is done. Um, um, I'll speak to the doctor and we'll speak to see. Okay. Well done. Um, it is difficult, like as you probably realize there's so many questions that you kind of need to, uh, so many things to kind of get through and it's always harder, kind of being put on the spot as well, especially when you've got everybody else kind of listening in. But thank you. That was actually, it's, it's kind of, yeah, it's always hard to kind of put yourself for, but I really appreciate you kind of um being the first one to kind of say yes and everything. That's great. Um What did you, how do you think that went? Let's, let's start with that. I think, I think my structure was a bit um not very organized as I wanted it to be. I think um there are a few questions like with the extra other questions that you ask in obstetric history compared to like a normal history taking. I think that just that made it a bit more difficult, but it's okay. Yeah, I think he uh I, I think it's fine, like sometimes you kind of do a history of like, oh you feel a little bit all over the place, but that's okay. The important thing is that you asked all the questions that you needed to ask and the, the and the order and the kind of format of it will come with time. Um But I think that you actually you did really well, you asked all the questions you needed to ask. Um and there, there were a lot of questions to ask. I think you got most of the relevant points actually across and you kind of got the points for the patient manner. You kind of asked me what I was worried about all of those things. I think you did quite well. How would you kind of present this history back? Yeah. Uh, I spoke to a 30 year old, um, lady today. She is, um, gravity too. I'm gonna gravity one high. Right. Sorry. Gravity to Parro one yesterday to P one. Yeah. Do two P one. Um, she has 32 weeks into her pregnancy and she presented with lower abdominal pain, um, with bright red uh vaginal spotting as well today morning. Um she doesn't have, she has, she has a background of um preeclampsia from her previous pregnancy and currently has also gestational hypertension and is on labetalol and Nifedipine for that. Um no other medical conditions. Um no previous surgeries. Um no um S T I S or public inflammatory just see this. Um So in terms of differential diagnosis, um I think my top differential would be placental abruption because or placental previa, I'm not too sure because it's a painful bleeding, but she described it as bright red blood, which I think is more aligned with the placenta previa. Um um She also reported decreased fetal movements. So going forward, um my time would be to do um to do a full examination upset because I'm nation um possibly um do a Doppler um listen to the fetal heartbeat using a Doppler. Um But if possible, I would like to do a C T G um um do a urine dip. Um just get a normal ops, um, take her blood group and save um, just in case it becomes more serious and to prepare for transfusion. Um, in terms of investigation. Do you want able to sound perhaps? Um, yeah. Okay. Yeah. Um, there was one other thing that I think you, you might do in someone who's coming in with, with bleeding and pregnancy. What else would you do by the bedside? Um, because what do you kind of want to know really well can, what, what, what do we love doing in Gynie Vaginal exam? Yeah, you, you, you want to do a speculum basically to see kind of how much blood is there. Whether the office is open, you kind of want to know those things and carrying on whether whether the office is open, you also want to ask him if she's got a history of shrum. Um So any history of like spontaneous rupture of membranes, history of fluid leaking that sort of stuff as well. And there's one other thing is just asked about cervical smears as but less relevant by anyone just good to ask, especially with TV, bleeding. Um Yeah, probably good to kind of know. Um You know, I think that I think the way that you presented it was really good. Yeah, so 30 year old uh para one, you know, sometimes we don't even use, we actually don't even say gravidity actually in real life where you just say this is para one she's a primer anyway, para one previous um SVD 32 weeks pregnant, constantly abdominal pain associated with an episode of um P V spotting. Uh and she's also reports would use fetal movements otherwise she's been well, no infective symptoms, no previous episodes of bleeding. Um pregnancies. You mentioned the preeclampsia which is being treated with kind of oral antihypertensives. You can also mention that scans. The other thing that would be good to know is does she have a low lying placenta on previous scans? Because then that would push your placenta, previa higher up. So you can say that a previous scans have not shown a low lying placenta. That's an important negative finding that kind of makes sense. But I think overall actually that was really good, really good differentials um and good kind of next steps as well today, bedside bloods and investigations and bloods as well. You kind of want to do your full preeclampsia blood. So you wanna do FBC to look at the hemoglobin, check your platelets as well because you can get help syndrome, check your LFTs, check the renal function, um check um What else? Yeah, LFTs and then check the CRP less. You know, we need to do CRP. You're concerned about infection and then definitely do group and save as well. Oh yeah, you mentioned CTG be. Yeah, that was really good. Um Anyone else have anything else? They want to add any, any questions about this case? In particular, let me just check the time. Okay. Any questions feel free to uh the message in the chapter on you? Um Okay. Now for the questions and if I can just ask, uh you said how many more cases? Yes. So this is the thing I just said, I just check the time actually because um are we planning on finishing it at uh eight o'clock? Yeah. Eight. Yeah. Yes, I think what we'll do is we'll do one more case. Um And then what I can do is when I send the slides across, I can just send like a little vineyard that you guys can use to practice. Um um I think that's probably a bit more kind of reasonable. Um So, yeah, so let's do one more case. I've got this one's a bit more similar. It's kind of vaginal bleeding again. So like we can skip this one, but I'm happy to kind of send you guys a little vignette. Um So you guys can practice. Um Let's do, let's do this one actually. This is um sort of postpartum pyrexia. Um Yep. So let's, let's, let's do this one who wants to kind of volunteer for this month. You eat a mute and it's a bit of the to nitty to practice the head of the placement for exams in a safe speed. Alternatively, we could do as a team based effort and we can either contribute, question, prepares and either meeting or in the chat of TV. Yeah. Yeah, we can always do that as well, actually. So you can have one person on the spot but it's up to you. Can you try? Yes, of course. Um, what was forced part and give it to go? Yeah. No, no, no, for sure. I think it's, um, this one, I mean, and then it's a bit a bit more straightforward because you have less of like, the pregnancy kind of questions to ask about and it's a bit more like a general history. Um, yeah, because it's just like a yes. Too much to ask. And fever. Yeah. Yeah. But it's a, if you think about it like a post surgical fever kind of thing, it kind of makes it a bit less daunting anyway. Um, but no, no, for sure. Let's, um, let's, let's, let's give it a go. What was your name? Sorry. So, my name is Belgian Decor, one of the physician associates secondary student. Okay. Great. Okay. Fine. Should we, should we start? You can introduce yourself and then do the whole history and stuff. All right. Hi. Good evening. My name's Belgian Decor, one of the physician associate. I've just been asked to ask you some questions regarding your visitor here today. So, could you confirm your name and date of birth before I start, please? Uh Yes. So I am, let's be the same list. Let's be myself again. I am Priyanka and date of birth. Is 19th of February, 1994. And how old that make you drink a, please? 29. Thank you so much. So how can help you today? Proenca? Um Yeah, so I instead of coming to triage just because I've been feeling quite unwell actually for the last kind of two days, been feeling really feverish, um bit nauseous, kind of like completely lost my appetite. Um I had my baby a week ago. Um It was all fine. Thank you. Thanks. Um Yes, it's like this is my first baby. So it's kind of um it's been a lot uh to kind of go through. But um, I mean, I was doing quite well actually for the first couple of days and then it's just kind of just been feeling really unwell last two days from last two days. Okay. So, uh is there any pain? Have you noticed? Uh, no, no, no, no, no pain. I mean, no pain, really? No pain. Okay. And you said you lost your appetite as well? So you're not eating and drinking much either? Yeah. And you had your baby? It was that a normal delivery or was it uh c section? It was a C section actually. Is this section? Yeah, you had to do it as an emergency. Oh, so his emergency. Okay. And was that uh is there any inflammation have you noticed or any using from the wound? I mean, the wound is, I mean, you did you did ask that pain, the wound is a little bit painful but I just thought that it was like regular pain. Um, but there's no redness. They kind of told me to look out for, like, redness and like something leaking, there's nothing leaking from the wound that's not really red or anything. No. Like, so just a mild pain around that area. Yeah. Yeah. Okay. And, and you haven't seen any blood on the addressing or anything like that? Yeah. Right. Ok. And um, I'm just trying to think, um, did you said this is your first baby? And are you feeding the baby or breastfeeding? Yeah. Yeah. So I have um, have been breastfeeding but I haven't really been able to over the last kind of, um, uh, the last day actually. Okay. And how's your energy level? Um, just really, really tired, really exhausted. I can understand. I can understand. Yeah. Um, and uh, you haven't had any, um, um, thoughts of any self harm or kind of things like that. Um, no, not really. I mean, I, I have been, my mood's been a little bit kind of up and down. Um, just kind of extra after delivery, just kind of trying to process, you know, the emergency C section. I, I really was like quite, I really wanted a normal delivery and then kind of, lots of things happened and I had to have an emergency C section. So I kind of trying to process all of that. So it was, it was a lot to process, especially initially, but I think my moods like a lot better now. Actually, I can understand. It's a bit overwhelming with the first child and going to the C section. So I can, you can really totally understand that. So, uh coming back to it, um just gonna ask you like, uh we do suffer from any medical conditions that you see, um any G P for. Um, no, no, not really. I'm pretty frightened but otherwise, yeah. Okay. And that was you, was you taking any antibiotics during the uh the C section? So they gave me kind of one dose of antibiotics, I think at the time of the C section. Um, but then yeah, that's, it didn't really give me anything to go home with. Okay. And there was no pain at the time or anything they've given you. Uh, no. So I had a bit of a bit of pain sort of luxury after when I woke up just around the C section where they made the cut, but then it sort of got better. They gave me some pain killers and stuff. So, are you mobile walking about or did they give you some injections to take uh oh, the blood thinning injections. So, yeah, so they did give me blood thing injections for 10 days. I'm kind of coming to the end of the course for that, but I have been walking around and stuff here you are walking about. Okay. Right. Um So you haven't seen, just want to ask, have you seen any discharge coming through the vagina or anything, uh, any discharge? So initially, it was a little bit of like they told me to expect like a bit of bleeding at the start, but it's definitely been lighter than a period and there's no discharge or anything. It's just like the, you know, the normal bleeding that you have after that settlers now settling. Now. Thank you. And when you pass the urine and did you see any, do you feel any sense? A burning sensation? No, no. Okay. Thank you. And just gonna just gonna ask, uh, I understand you had just given birth to the baby and it's difficult to answer. Um, you know, it's actually active at the moment. Are you? I'm sorry, I was just gonna Yeah. No, no, no, no, no, no, I'm not. No. Thank you sort of recovering from the surgery and everything I can understand. I'm sorry. Just one of the screening questions I thought I asked. No problem. I understand. Not when they're irrelevant. But yeah, and you don't take any medication except you said the blood thinning tub, blood thinning and there's some many painkillers. Um, yeah, nothing else. Nothing else. Okay. And just gonna ask you some are, you know, you're allergic to anything I should know. Break. No, no allergies. Ok. Um, and, uh, anything in the family history of, uh, any. No, nothing. Okay. And of course you're not working right now, but, uh, you don't smoke or drink during the pregnancy or? Uh, no, no. Yes, I haven't had, I haven't, I've never smoked and I haven't been drinking. No, thank you. I understand. So, um, really that was about more questions I can think of. Um, yeah, thank you so much prank. Uh, I'll just to speak to my senior. I'll come back to you. Is that okay? No worries, no worries. Um Okay. Do you have any other questions that you want to ask? I forgot to ask about your ideas and concerns. What do you think? What's going on? Okay, here you go for it. You can ask me. So, what have you got any idea prink of what's actually going on? Um I don't know. I mean, I'm a little bit concerned about sort of like, I haven't been able to breastfeed really for the last kind of day or so. So immediately kind of like after I gave, but my like my breasts were quite sore, but then I've sort of been using like lotion and stuff like that. And also it's been like, it's because it's my first baby. It's been a bit tough for the baby to kind of like latch on and start breastfeeding and everything. But my uh my breast has become really sort of uh really, really kind of read over the last kind of uh last day or so I would say. So I am a little bit concerned about that. Actually, I just don't know, I don't know what it is. Is this normal? I'm not sure because this is all kind of quite new to me. That's just the thing that I was concerned about. And then I was also just worried about whether this fever is coming from the wound, from the, you know, the C section um where they did the C section as well. So I'm kind of just want someone to have a look at that as well. Understand. So you said the breast a bit sore and which, which side of the breast is? So, so it's the left breast, left breast. So and uh is it when you touch? It is painful? Yeah. Yeah. It's really painful. Yeah. Is it just close to the nipple or just just a little bit above the nipple? So it's kind of like all around actually. And it feels like it's like the redness is kind of like spreading, right? Okay. And you haven't seen any puss coming out of it or any uh discharge coming out more. She said it's gotten pain like painful and like red and hot to touch. Okay. Thank you. Understand that. OK. Just going to ask you some general question of your health involving. You haven't noticed any chest pain or anything like that. No chest pain, any shortness of breath. No, and I understand you mentioned that you're eating and drinking. Not as great at the moment here, which is understandable with the fever and sickness and uh any headaches or any visual changes. No, no. Okay. And uh any diarrhea or any constipation, any bowel changes and passing you and you already mentioned it's okay. There's no pain, right? Thank you so much Brinker. I understand what's going on now. So I just quickly chat with moist um consultant. Come back to you. Is that all right? Yeah, no worries. Thank you. Thank you. Ok, great. Uh So do you want to present, do you want to take, take, take a second, then you can present that history back and then we'll kind of talk about how you thought that went and then what you would do differently next time. Mhm. Okay. I feel free to start presenting when you're ready. Okay. Yeah. So uh like I've just seen praying cause she's 29 years old Gravity one and para one. Um just given birth two days ago, two. Uh sorry, I forgot to ask baby boy or a baby girl. Anyway, it's a baby girl. Yeah, to give birth to baby girl with the C section. It was emergency C section. They have to perform. Um She is feeling uh my positive uh findings are just feeling for feverish, nauseous, lost appetite, a bit, uh breast left breast tenderness um and if the redness is a spread in and it's a bit painful on that side as well and she is not able to feed the child as no known allergies and uh there's no family history or any medical condition. Uh Priyanka sees anyone. Uh So my top differentials are in here is uh mastitis. Uh I can also say maybe breast sepsis and uh uh I can, I can really say pure do a range which is kind of lower on the list. But my top differentials is uh MS itis okay. And what would you do next? So, um I would like to um consent general blood's um I'll do them my basic vitals. So check the check or um check the BP and all the basic vitals. Um I will send the blood to check the fpc's any infection markers raised up. Um I might just do a quick breast examination. I understand it's a bit painful and tender, but just want to see actually what's going on, what's causing it. And after that, uh um yeah, that's about it. And I think in this case would like to ask the surgeon if he's happy to prescribe some antibiotics to give to the patient. Anything else that you would do or examine? I would look at the C section where uh the C section, the wound is okay. Any discharge coming out of it or any tenderness. Uh If I needed to change address, now, we'll do that as well at the same time. If there's any um stitches underneath are still okay. Uh So check on that one as well. Yeah. Um I might just do gentle tender abdo check, which doesn't really need it, but just quick check. Um Yeah, okay, great. And what are your main different? Do you, you mentioned the main differentials already? Um that that was good. Um This is just to kind of just say that like don't forget uh the main reason why I put this case in is to kind of just kind of uh firstly, highlight the fact that obstetric history is not just somebody who is currently pregnant, it could be somebody who has finished their pregnancy kind of like a week ago, two weeks ago. So you might see someone post partum as well, just think about all of your postpartum conditions as well. So um fever in the post uh post partum period or POSTOP period, think about bleeding as well. Um sort of secondary PPH. Um And then think about things like your, like you guys mentioned already kind of like postpartum psychosis, postpartum, mental health problems, all of those things as well. That was the first reason why I mentioned. The second reason is because whenever we think of fever, post C section, you think is it coming from the C section wound? That's, that's like your first thing, right? Just kind of think about like also ask about the breast as well. Mastitis as well. Could give you fever. So always, just always just don't forget to ask about the breast. So we kind of don't really ask about the breast and kind of your antenatal history. But it is a bit more relevant kind of postnatal, especially with breastfeeding and all of those things. And also just kind of just ask about your other sources of fever. So as you did ask about meningitis, ask about the chest, ask about the abdomen, ask about urine, ask about all of those things and you rightly asked about like discharge and stuff as well and you asked about bleeding and stuff that was really good um with regards to your next step. So I think, try and make it a bit more kind of organized. I just think what can you do by the bedside? So I've done a history already, I'm gonna do a full examination which would include a breast exam and that would include um an abdominal examination as well, looking specifically at the C section wound. I'm also going to do a urine depth, do a full set of bloods, including FBC, use any CRP. Um And I'm going to also, I mean, that's pretty much it really and then kind of decide on whether you need to do any further investigate imaging or anything of the breast. But I think that would kind of, you, you, you might not, you'd have to discuss that with a senior and see if they would suggest anything really. But if you, you were able to like palp a like a collection or anything under a C section wound, then you could do an ultrasound. And the reason why you would do an ultrasound is because you can see if it's a massive collection, if you can drain it through like i our drainage and stuff like that. So that's why you would think about like any further imaging. Um Yeah, those and then your, your next steps and after that would be with because of your management always can have mentioned you would discuss your plan with the senior and some of that just kind of like safety netting and stuff. Um Yeah, but that was really good. Well done. I think it's, it's a difficult one because we've kind of been talking so much about like obstetric and like antenatal kind of history. I was thinking to ask Shelly, ask all the electrical, see there's no point, you know, the scans and business because, you know, you made your plan that, that this is how you can ask, but this is totally different with the fever. Yeah, I was actually thinking Subsys maybe because of the C section. Yeah, and that was my in my mind as well. But I asked about if you're feeding the baby but didn't think of the cystitis, which is the normal. Yeah, but I think you got it when you were like, what are you concerned about? And sometimes that can happen. But you're like you ask the patient or what do you think this could be? What are you concerned about? And then they kind of guide you to like the right kind of way. The other thing that I was going to ask was just kind of, yeah. So I think I wouldn't ask about, I would just ask, did you have any issues with the pregnancy? That's kind of as much as I would go because actually you kind of want to do focus history. Taking. The only other question I would ask is why did she have an emergency C section? That's the only thing I mean, it's, yeah, it's might not necessarily kind of change stuff but just a good thing to kind of know you're presenting back. Yeah. Um Any questions that's okay with that. Now, that was really good. Well done. Tried. Thanks. Any other questions from anyone else do you agree to based on the chat if you have any questions? And if I just may add actually to uh those sorts of histories in the postpartum phase, especially when they're mentioning about difficulty feeding, caring for the baby, you bring in a little bit of neonatal elements that you're the holistic elements such as in the management side at least. So, you know, consideration of breastfeeding, support midwife um for again, revision on how to breastfeed techniques and etcetera or there's genuinely an issue uh such as mastitis, then you know the management planning that is to encourage breastfeeding, at least breast pumping and so on and so forth that will come in. Um And also in terms of the baby's weight, if they're not receiving adequate nutrition, you may want to consider neonatal involvement because as my mom has you noticed in it, it's as a weight loss in a child, that kind of thing as well. Um Just, just more for generalistic plus exam purposes. Um It shows that you're sort of thinking holistically about the patient, which will get you extra brownie points both in real life and in exams, I think. Yeah, that's a very good point. Thank you. All right. Any questions from anyone else? Okay. Um So just kind of key take home message is I guess so first thing which we kind of haven't mentioned during this during the talk, but just consider clinical context. So where are you seeing this patient? Is it in an Antenatal clinic setting? Are you seeing them in triage? Are you seeing them on labor? Would I was just something to kind of think about? Like what is your context where where are you seeing this patient? Ask about current and previous pregnancies? Take time to kind of consolidate the information that you've gathered from your in depth history taking before for you actually present it back. It just means that you're a lot more slick, you kind of have your thoughts in order before you kind of present back. And also just helps in kind of like a stressful situation just to kind of take a step back. You're kind of a lot more calmer when you kind of come back and present it. And then this is just kind of like when you're revising in groups, um just have differential diagnosis in your head for each of the obstetric symptoms um that women are more women are likely to present with and that's gonna guide your focus, history taking. And then these are just some useful resources. So this is a textbook that I used to Lawrence in P and Tim Child, one obstetrics and gynecology, which is the one on the right. Kiki medics is really good because they've got like, um they've got these like interactive kind of um what do they call it for? Like for like each history, they've kind of got these Actiq boxes where you can like go through and especially when you're practicing history that someone to check if they've at all, like they've ticked all the boxes and stuff even though they do tell us like it's not a tick box exercise. It's about like general impression and how you are a patient safety, patient manner and stuff. There are still kind of like certain specific questions that you should be asking. So it's good to kind of get those specific questions across. And some of the cases that I took were just from this book, I just found like a PDF online. I just took some cases from there. Um Yeah, those are just some of the useful resources and the most useful resources actually just the people around you. So I think I would definitely say, I think actually for like, aw skis and stuff, um It's super, super useful to just kind of have like a group that you kind of practice or just go and practice all those like histories and stuff. And for those of you who are like starting placements and stuff, it's really good to kind of now that you've got this kind of basis of how to take an etcetera history, go and practice, go and see patient in the early pregnancy unit and then just practice presenting back and the more you present back the most like you'll get, the more you'll kind of be comfortable asking these kind of questions and stuff as well. Um So, yeah, that's kind of everything actually. Um from my side, I'll stop presenting just so um Anamika can then kind of share the feedback link. But I hope you guys sort of enjoyed. I know that a lot of it's just stuff that you probably know already. So hopefully it was a good recap and you guys kind of are able to take something away from the session. Thank you. Okay. Thank you all so much for joining and for your amazing participation. That was very interactive and thank you. So much Priyanka for leading such an amazing session. I'm sure everyone will agree that was extremely, very useful. Um And you went over such a wide variety of topics. So, thank you very much. All right. Thank you. Thanks guys. Yeah, thank you for interacting. It kind of makes such a difference actually, too kind of uh bounce ideas across and stuff. That was great. Thank you. Uh So if I can please request everyone to, if you can provide feedback, that'd be absolutely great. Um Not only will it help our speaker's, but it will help us as being, getting continue to deliver and improve our talks. So we're making sure we're patron for your needs and of course, by filling the feedback, you'll be able to access the recording's on the slides. Uh Once we have those available. Thank you very much. I'll just keep this open in case anyone still feeding, uh putting the feedback in. If you do have any questions, don't hesitate to contact us via uh social media or email beamer as well. We'll be happy to help. Okay.