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When the DRCOG and MRCOG had clinical exams, my trainees were drilled to follow a set routine to take and present a history.
The aim was to help them ensure that they did not forget something important like the family history.
And that they presented the information in a problem-oriented way.
It worked well.
Many MRCOG candidates do not have a model for taking a history.
Most hospitals have a pro-forma for taking a history in the antenatal clinic.
And much of this may have been completed by a midwife before the doctor sees the patient.
This is not good preparation for a MRCOG OSCE station where you could be asked to:
take a history,
and then present it and a management plan to the examiner,
You need to memorise a model so that you make sure that all of the headings below are included.
It is not as bad as it looks.
In the exam they have to give you a manageable task, so she is not going to have had:
ten complicated pregnancies,
four Caesarean sections,
diabetes,
a history of puerperal psychosis, and use of 3 herbal remedies of which you have
never heard!
including screening for depression, domestic violence and VTE
What screening and diagnostic tests have been done for fetal abnormality? What are the results?
The following layout would apply to the station in which you were starting from a base of no information.
I. e. your instruction is just to take a history without any clue about whether or not there is a problem.
The layout would need to be modified for the patient who presents with a problem.
E.g. if she came to discuss Down syndrome screening you would start by:
finding out if there is a particular reason for her wishing to discuss screening,
usually there will be an affected relative: show your humanity by asking how they are,
finding out what she knows about Down syndrome,
explaining Down syndrome if she does not already understand it adequately,
explaining her risk, which is complicated if there is a risk she has a balanced translocation,
explaining the available methods of screening,
explaining that screening is basically just about refining the age-derived risk and is not diagnostic,
explaining about diagnostic tests and the associated risks, particularly miscarriage,
discussing their views on TOP in the event of Down syndrome being found,
discussing screening and diagnostic tests if they would not have TOP whatever the outcome.
This would probably generate about 60% of the marks.
Then you would go on to do the rest of the history, so the sequence would need to be altered.
When something crops up, make use of it.
It may not be immediately apparent why it is important.
So make a mental note and cross-reference it with each subsequent bit of information.
In the MRCOG there will usually be something behind each fact.
Why did she have Caesarean section with her first pregnancy?
What type of Caesarean section was it?
Were there any problems with the surgery?
Did she have any problems afterwards?
Where is the
placenta this time?
Introduce yourself / check her name and age.
Use the standard form of words in the communication section.
If you don't like them, devise your own superior version and let me know what it is.
2.
Is this her first pregnancy?
It is important to know
which pregnancy this is.
If planned, did she have pre-pregnancy counselling, rubella screening etc?
Did she take folic acid?
Did she keep a record of
her periods?
If not planned, there are important implications.
How did she react?
Did she consider termination?
How did her partner / family react?
Has it caused any problems with them?
Have these been resolved?
Did it cause other social
problems: housing, financial, work etc. and have these been sorted out?
Reacting negatively and considering termination can impact on her psychological state later.
With a healthy baby she may feel guilt that she considered killing it.
If she miscarries or has a
stillborn or handicapped child, she could come to believe that she is being
punished for her previous wicked thoughts.
This information tends to be scattered through the notes.
Usually there are separate sections for menstrual history, contraception, bleeding and scan dating.
It makes sense to gather it into a single section.
Date of LMP.
What was the length and regularity of the previous cycles?
Did she have abnormal bleeding before the LMP?
Has she bled since the LMP?
Was she on the Pill?
When did she stop it?
How many periods did she
have afterwards?
When was the first +ve
pregnancy test after the LMP?
Did she have an early scan?
Did it fit with the LMP?
Has she had any other scans?
Did they also fit with the LMP.
What is the best estimate
of the EDD?
5.
What tests has she had done?
She should have had all the usual tests done in early pregnancy:
Hb,
blood group,
MSSU,
screening for infection etc.
Did she accept the offer of HIV screening?
Specific questions you need to ask.
In particular you need to ask about:
depression: the Whooley questions
VTE risk
domestic violence
Have the Whooley tests been asked?
Has she been asked about thrombosis risk?
Remember that you are supposed to do a VTE risk assessment each time she attends.
With domestic violence you need to make it clear that all women are asked these questions.
"We ask all women about domestic violence.
This is where a woman is hurt by her partner.
This is a common problem: it affects one woman in every four at some time in her life.
They can be too scared and embarrassed to tell anyone about it.
If you have had any problems of this kind we treat it with complete confidentiality.
And can help you to deal with it.
Has anything of this kind happened to you?"
Were any of these tests
abnormal?
Did the doctors and midwives offer any other tests; she could have had:
thyroid function tests,
genetic screening for cystic fibrosis,
a glucose tolerance test etc.
What were the results of these tests?
Was she referred to any other specialists?
Why was she referred and
what was the outcome?
6.
What screening and diagnostic tests have been done to look for fetal
abnormality? What were the results?
Most will just have had:
biochemical screening for Down’s syndrome,
and a 20 week scan to look for:
neural tube defects,
other structural abnormalities,
soft markers,
placental site,
and number of fetuses.
Soft markers are usually optional, so you need to ask about them separately.
However, she may have had chorionic villus biopsy, nuchal translucency etc.
If the test is not routine, e.g. chorionic villus biopsy, ask
why it was done.
7.
Have any problems arisen? When did they start? How were they noticed?
Mostly you will be taking a history in the third trimester after a problem has been noted: bleeding, IUGR, SPROM etc.
Usually the pregnancy will have been normal until this.
8.
What has been the management up to now?
9.
What is the management plan?
A management plan may have been agreed - you need to know.
However, she may be a new admission and you need
to decide what tests to do and what the management plan should be.
The plan needs to cover:
the rest of the pregnancy,
labour,
delivery,
third stage and puerperium,
and might include breast-feeding, contraception and advice about future
pregnancies.
What are her plans?
Did she breast-feed the first baby and for how long?
Did she have any problems?
11.
Plans re further pregnancy and contraception.
This is fairly straightforward.
If she is undecided about contraception, does she know where to go for advice?
The remarkable problem is that we don't know the ideal inter-pregnancy interval.
The WHO has recommended:
an interval of at least 24 months after a mature pregnancy
an interval of at least 6 months after "abortion", which presumably means miscarriage + TOP.
http://www.who.int/maternal_child_adolescent/documents/birth_spacing.pdf
Numerous papers support this view: e.g. Smith et. al: BMJ 2003;327:313.
Grisaru-Granovsky et al, Contraception. 2009 Dec;80(6):512-8 found adverse outcomes, particularly preterm delivery, with intervals < 6 months and > 60 months.
They reckoned that the interval should be > 11 months.
But if the first pregnancy resulted in miscarriage, there is evidence that conception within 6 months is best.
Love et al. BMJ 2010;341:c3967
And how long does a CS scar take to heal?
There is some evidence that uterine rupture is more likely with conception < 6 months later.
Stamilio et al. Obstet Gynecol. 2007 Nov;110(5):1075-82.
For the exam I think you should state that IPIs , 6 months are less than ideal and that some authorities recommend a minimum of 24 months.
12.
Her health – present and past.
Do you have any health problems (other than the bleeding or whatever)?
Have you had any operations or illnesses?
Many people have had psychological or emotional illnesses like depression.
They may find it difficult to talk about.
Have you had any illnesses of this kind?
You can then ask targeted questions if need be.
Current drug use. Include prescribed medicines, “over the counter” drugs, herbal remedies etc.
Alcohol, tobacco and street drugs. Allergies.
You already know which pregnancy it is.
Now find out everything relevant about the previous pregnancies, labours, deliveries and afterwards.
Postnatal depression merits specific mention.
How are the children doing now?
If one of them has been found
to have cystic fibrosis, congenital heart disease etc. it has implications for
this pregnancy.
May be very
relevant e.g. myomectomy or uterine anomaly identified at laparoscopy.
May affect dates calculation.
If early pregnancy, IUCD and progesterone only contraception
linked to an increased ratio of ectopic: intra-uterine pregnancy.
When was the last smear?
Has she ever had an abnormal smear?
How has she and those around her adjusted to the pregnancy?
Is she in a stable relationship?
Will the pregnancy affect her work?
What about housing and money?
If a station is about pre-menstrual syndrome, postnatal depression or anything with a significant psychological component, you are likely to be dealing with a “hidden agenda”.
This is likely to be a problem generated by the partner: physical abuse, alcoholism etc.
But it could be that she was abused as a child.
This is covered at length in the document on counselling skills.
You can find it on the
web site: www.drcog-mrcog.info.
You have to ask and offer appropriate support.
This one of the topics like mental
“Many women suffer from abuse.
This can be physical or emotional.
It can be from their partner or someone else.
They usually find it too difficult to talk about.
Has anything like this happened to you?”
Are there any illnesses that run in your family?
If appropriate, ask the “targeted” question.
Have any of the women in your family had problems with pregnancy?
Have
any babies been born with a problem or developed one later?
Could there be a "hidden agenda"
This is unlikely if you have asked about the most likely one: domestic violence.
But keep it in mind.
He could have
health problems with potential impact on the child or their social conditions.
Ask the same
questions about his family that you did about hers.
23.
Presenting the information.
In the MRCOG you could have a preparatory station with a role-player.
And then move on to a
station with an examiner where you are expected to outline the history and your
management plan.
The
presentation goes as follows:
Summary of key facts.
If you are presenting a role-player and her history to a consultant in an OSCE, ask them their name.
In real life, you should introduce the patient to everyone present.
Do you always tell them the nurse’s name or that of the medical student?
It is basic good manners.
If you
don’t do it, you are already showing the patient that you don’t think she
matters very much.
a.
Present an outline of the key facts first, not the detailed history.
This is Jane Eyre.
Jane, this is Dr. …….
She is 35 years old and 39 weeks advanced in her second pregnancy.
The pregnancy was planned.
The main features are:
She has had insulin dependent diabetes for two years.
It is well controlled.
(Not. Do not say: “she is a diabetic”.
A major flaw in doctors is to put patients into categories.
This depersonalises and devalues the individual.
I would ask in theatre: “have we sent for the next patient”?
Almost always the reply would be: “it is on its way”.
This never failed to give me the horrors!
It also leads to absurd expressions of which we seem uncritical: “the hysterectomy in the third bed has a fever”.
So, you must use descriptive phrases: “she has diabetes”.
This may seem a small and insignificant matter.
It is not.
It forms part of the framework of your relationship with the patient.
You harm her if she feels that
she is of no interest or value apart from her illness.)
She had Caesarean section for placenta previa at 35 weeks with her
first pregnancy after a massive bleed.
She had four units of blood.
(If the history points to a possible risk in this pregnancy, point it out.
Even if the history has excluded it.
In this case: “the scan at 20 weeks showed the placenta to be high and
posterior”.
The baby is called
She has been admitted for Caesarean section tomorrow as the baby is
presenting by the breech.
b.
Then go through the history, heading by heading.
You
are now adding the detail.
When
talking about the proposed management & Caesarean section you might add:
she
has been fully counselled about the risks.
Her
blood tests are normal.
She
has been seen by the anaesthetist.
Spinal
anaesthesia is to be used.
A
plan has been prepared for the management of her diabetes.
Watch
the time.
If
you have been asked to give a management plan, a third to a half of the marks
are likely to be for this, so leave enough time.
c.
Finally, it there is time, repeat the summary of key facts.
This can be even briefer.:
"In summary.
This
is Jane Eyre.
She is to have Caesarean section under spinal anaesthesia tomorrow for breech presentation.
She had Caesarean section with her first baby.
An ultrasound scan has shown a normally-situated placenta.
She has well-controlled diabetes.
There is a detailed plan for the management of her diabetes".
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