As an admitting Medical Officer in a women's hospital like the German Sri Lanka Friendship Hospital for Women in Galle, the initial assessment of obstetrics (Obs) and gynaecology (Gyn) patients involves systematic history taking, physical examination, and accurate documentation in patient notes or the Bed Head Ticket (BHT). This ensures comprehensive care, identifies risks early, and aligns with Sri Lanka's national guidelines for maternal and reproductive health. The process is multidisciplinary, emphasizing empathy, cultural sensitivity, and privacy, especially in a diverse population.

History and examination are often overlapping for Obs and Gyn cases, as many patients present with mixed symptoms (e.g., bleeding in pregnancy or gynecological issues). A combined approach is efficient, with specific tailoring. Recording uses standardized notations like G (Gravida: total pregnancies), P (Para: viable deliveries >20 weeks), or extended forms like TPAL (Term, Preterm, Abortions/Miscarriages <20 weeks, Living children). For example, "G2P1" means two pregnancies, one viable birth; "P2 C1" might locally denote Para 2 with 1 living child, but confirm with guidelines.

Key resources include the National Guidelines for Maternal Care Volume I (2013) available here and Volume III (2015) available here from the Family Health Bureau (FHB), Ministry of Health; the Maternal Care Package: A Guide to Field Healthcare Workers (2011) available here; and SLCOG guidelines on various conditions. These emphasize evidence-based, woman-centered care.

Start with building rapport, explaining the process, and obtaining consent. Use open-ended questions, then probe specifics. Document in SOAP format (Subjective, Objective, Assessment, Plan) or chronological notes.

• Personal and Demographic History: Name, age, address, contact, marital status, education, occupation, socioeconomic status, and consanguinity. Note habits like smoking, alcohol, betel chewing, or substance use.

• Menstrual History: Age at menarche, cycle length/regularity, last menstrual period (LMP), flow duration/amount, dysmenorrhea, or intermenstrual bleeding. Calculate estimated due date (EDD) if pregnant: EDD = LMP + 280 days.

• Contraceptive History: Methods used, duration, failures, and complications (e.g., IUD-related infections).

• Sexual History: Partners, dyspareunia, sexually transmitted infections (STIs), and safe practices (sensitive inquiry).

• Medical History: Chronic illnesses (diabetes, hypertension, thyroid, asthma, heart disease), allergies, medications, surgeries, blood transfusions, and immunizations (e.g., rubella, tetanus).

• Family History: Genetic conditions, diabetes, hypertension, twins, congenital anomalies, or cancers (breast, ovarian, cervical).

• Social History: Support system, domestic violence, nutrition, housing, and access to care. Screen for mental health (depression, anxiety).

• Presenting Complaint: Chief symptom (e.g., pain, bleeding, discharge), onset, duration, severity, aggravating/relieving factors, and associated symptoms.

Focus on current and past pregnancies. Use the Maternal Care Package guidelines for antenatal admissions.

• Present Pregnancy: LMP certainty, EDD, symptoms (nausea, vomiting, bleeding, pain, fetal movements from ~18 weeks), antenatal care received, scans, tests (e.g., OGTT for GDM, Hb for anemia), complications (hypertension, GDM, infections like malaria), and concerns.

• Obstetric History: Gravidity (G: total pregnancies), Parity (P: deliveries >20 weeks), miscarriages/stillbirths, term/preterm deliveries, mode (vaginal/cesarean), complications (PPH, preeclampsia), neonatal outcomes (birth weight, anomalies, SCBU admissions), and breastfeeding.

• High-Risk Screening: Previous cesarean, multiples, Rh-negative, grand multiparity (>4), or age extremes (<18 or >35).

Emphasize reproductive and non-pregnant issues.

• Gynecological Symptoms: Abnormal bleeding (menorrhagia, metrorrhagia), discharge (color, odor, itch), pain (pelvic, dyspareunia), urinary/bowel symptoms (incontinence, prolapse), infertility, or menopausal symptoms (hot flashes, vaginal dryness).

• Past Gynecological History: Surgeries (hysterectomy, laparoscopy), infections (PID, STIs), smears (Pap test results), endometriosis/PCOS, fibroids, or cancers.

• Screening History: Well-Woman Clinic visits, mammography, or HPV vaccination.

Perform in a chaperoned, private setting with consent. Start with vitals: BP, pulse, temperature, respiratory rate, weight, height (calculate BMI). General exam: Pallor, edema, jaundice, thyroid, lymph nodes, breasts (lumps, nipples).

• Cardiovascular and Respiratory: Auscultate heart (murmurs) and lungs (wheezes, creps).

• Abdominal Exam: Inspect (striae, scars, distension), palpate (tenderness, masses, fundal height in Obs), percuss (fluid thrill for ascites), auscultate (bowel sounds, fetal heart in Obs >12 weeks).

• Abdominal Palpation: Symphysio-fundal height (SFH: matches weeks from 20-36), lie (longitudinal/transverse), presentation (cephalic/breech), position, engagement, amniotic fluid, fetal heart rate (Doppler from 12 weeks).

• Vaginal Exam (if indicated): Cervical status, membranes, show, or bleeding. Avoid routine in early pregnancy unless necessary.

• Legs: Varicosities, edema.

• Pelvic Exam: Speculum (cervix, discharge, lesions), bimanual (uterus size/position, adnexal masses, tenderness), rectal if needed (for prolapse or masses).

• Additional: For prolapse, Valsalva maneuver; for infertility, assess secondary sexual characteristics.

Document clearly, legibly, and chronologically in the BHT or clinic record. Use standard abbreviations.

• Obstetrics Notation Examples:

  • G3P2: Gravida 3, Para 2 (3 pregnancies, 2 viable births).
  • G4P2+1: Gravida 4, Para 2 with 1 miscarriage.
  • TPAL: T2 P0 A1 L2 (2 term, 0 preterm, 1 abortion, 2 living).
  • If "P2 C1": Could mean Para 2 with 1 child (implying 1 loss); clarify with full history.

• Gynaecology Notation: e.g., "Menorrhagia with fibroids, Pap normal 2024."

• Structure: Date/time, subjective (history), objective (vitals, exam findings), assessment (diagnosis/risks), plan (investigations like USS, bloods; referrals; follow-up). Include risk factors (e.g., high-risk Obs: refer to consultant).

• Investigations: Order based on history/exam: Hb, urine protein/sugar, VDRL, blood group/Rh, OGTT if risk, ECG/echo for heart issues.

In admissions, prioritize emergencies (e.g., bleeding, pain) and document consent for procedures. Review records for continuity. If unsure, consult seniors or SLCOG guidelines.

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