Station 67 Child immunisation programme 185
That having been said, they are still very common in some other countries, from where they may be
reintroduced to unvaccinated children in the UK. Vaccines can and often do have side-effects, but
and a fever. Some vaccines are given together in a single injection so as to minimise the number of
• Measles can cause pneumonia, fits, encephalitis, sub-acute sclerosing panencephalitis, and
• Mumps can cause meningitis, encephalitis, deafness, and sterility.
• Rubella in pregnancy can cause severe damage to the foetus.
• The MMR vaccine is safe and effective, and more than 500 million doses of the vaccine have
• Common side-effects of the MMR vaccine are a sore injection site and flu-like symptoms. Very
rarely, an allergic reaction can occur.
• There is no evidence to support a distinct syndrome of MMR-induced autism or inflammatory
• Separate administration of the measles, mumps, and rubella vaccines provides no added
benefit over administration of the combined MMR vaccine, but means three injections and
potentially delayed or missed vaccinations.
• Introduce yourself to the patient and confirm his name and date of birth.
• Explain that you are going to ask him some questions to determine the nature of his problems,
• Ensure that he is comfortable.
• If he has glasses or a hearing aid, ensure that these are being worn.
• If appropriate, ask if you can take a collateral history from a carer.
• Enquire about the patient’s presenting complaint, if any. Use open questions and active listening.
• Explore any symptoms, e.g. onset, duration, previous episodes, pain, associated symptoms.
• Enquire about the effects that his symptoms are having on his everyday life.
• Elicit his ideas, concerns, and expectations.
• Physical independence, e.g. describe a typical day.
• Functional assessment: can he stand up and walk, climb the stairs, get on and off the toilet, get
in and out of the bathtub, dress, cook/clean/shop, and manage his finances and administration?
• Daily diet, including nausea, vomiting, and change in appetite or weight.
• Urinary and faecal incontinence.
• Mood (e.g. “How are you keeping in your spirits?”). Also ask about sleep and appetite.
• Memory and cognitive impairment.
• Dizziness/falls (see Station 31: History of ‘funny turns’).
• Vision (corrective aids, accidents, difficulty reading, feeding, dressing, grooming, driving, and
• Current, past, and childhood illnesses. Ask about rheumatic fever and polio.
• Prescribed medication and compliance (note that polypharmacy can lead to adverse interactions).
• Parents, siblings, and children. Ask specifically about diabetes, Alzheimer’s disease, and cancer.
Station 68 Geriatric history 187
• Occupation or previous occupation.
raised toilet seat, shower stool, bedside commode.
• Carers and support services.
ill?” and, “Who should make decisions for you if you become too ill to speak for yourself?”
• Ask the patient if there is anything that he might add that you have forgotten to ask about.
• Ask if he has any questions or concerns.
• Indicate that you would like to examine the patient and order some investigations.
• Formulate a problem list and suggest treatment options.
Geriatric physical examination
Temperature, pulse, blood pressure (lying and standing), respiratory rate, height, weight.
Nutritional status, posture, tremor, gait, aids, e.g. for walking or hearing.
Vision (including fundoscopy), hearing, mouth, throat.
Arthritis, muscle wasting, contractures, tenderness, bone pain, range of motion in different joints.
Arrhythmias, added sounds, murmurs, carotid bruits, pedal or peripheral oedema, absent peripheral
Chest expansion, basal crackles (may be difficult to hear because of basilar rales/crackles).
Organomegaly, bladder distension, abdominal aortic aneurysm, frequency and quality of abdominal
Tone, power, sensation, reflexes, gait, co-ordination.
189Obstetrics, gynaecology, and sexual health
• Introduce yourself to the patient, and confirm her name and date of birth.
• Explain that you are going to ask her some questions to uncover the nature and background of
her obstetric complaint, and obtain consent.
• Ensure that she is comfortable.
Presenting problem (presenting complaint)
symptoms, previous occurrences.
History of the present pregnancy
• Determine the duration of gestation and calculate the expected due date (EDD).
– ask about the date of the patient’s last menstrual period (LMP)
– ask if her periods had been regular prior to her LMP
– ask if she had been on the oral contraceptive pill (OCP): if yes, determine when she stopped
taking it and the number of periods she had before becoming pregnant
– determine the duration of gestation and calculate the EDD (to calculate the EDD, add 9
months and 7 days to the date of the LMP)
• Ask about foetal movements and, if present, about any changes in their frequency.
• Take a detailed history of the pregnancy, enquiring about:
– date and method of pregnancy confirmation
– was the pregnancy planned or unplanned? If it was unplanned, is it desired?
– symptoms of pregnancy (e.g. sickness, indigestion, headaches, dizziness…)
– chorionic villus sampling (10–13/52)
– type of antenatal care (e.g. shared care, midwife-led care, domino scheme, consultant-led
190 Station 70 Obstetric history
– antenatal clinic findings – you must ask about blood pressure and proteinuria
History of previous pregnancies (past reproductive history)
• Ask the patient if she has had any previous pregnancies.
• For each previous pregnancy, ask about:
– the duration of the pregnancy and any problems e.g. placenta praevia, abruption, preeclampsia
– the mode of delivery and any problems e.g. ventouse or forceps delivery
Do not forget to also ask about miscarriages, stillbirths, and terminations.
• Take a focused gynaecological history
• Ask about the date and result of the last cervical smear test.
• Current, past, and childhood illnesses. Ask specifically about hypertension, epilepsy, diabetes
• Recent visits to the doctor.
• Folic acid supplements (should be taken from 3 months prior to conception to 3 months into
• Rhesus antibody injections (if required).
• Parents, siblings, and children. Has anyone in the family ever had a similar problem?
• Is there a family history of hypertension, heart disease, or diabetes?
• “Is there a history of twins or triplets in your family or in your partner’s family?”
Obstetrics, gynaecology, and sexual health
Station 70 Obstetric history 191
• Support from the partner and/or family.
• Income and financial support.
• Ask the patient if there is anything she might add that you have forgotten to ask about.
• If asked, summarise your findings and offer a differential diagnosis.
Conditions most likely to come up in an obstetric history station
• In about 1% of pregnancies the fertilised egg implants outside the uterine cavity, most often
in the Fallopian tube, but also in the cervix, ovaries, and abdomen. Clinical presentation occurs
at a mean of about 7 weeks after the LMP, with a range of 5–8 weeks. Symptoms principally
involve lower abdominal pain which may be worse upon moving and straining, and vaginal
and internal bleeding which can be life-threatening. The principal differential is from normal
• In about 15–20% of all recognised pregnancies, the pregnancy ends spontaneously at a stage
when the embryo or foetus is incapable of surviving (before approximately 20–22 weeks
of gestation, although most miscarriages occur prior to 13 weeks of gestation). The most
common symptoms, which can range from very mild to severe, are cramping and vaginal
bleeding with blood clots. The principal differential is from ectopic pregnancy.
• In about 0.5% of pregnancies, usually during the second or third trimester, the placenta
attaches to the uterine wall close to or covering the cervix. This classically leads to painless,
bright red vaginal bleeding that increases in frequency and intensity over a period of weeks.
• In about 1% of pregnancies the placenta partially or completely separates from the uterus,
depriving the baby of oxygen and nutrients and causing heavy bleeding in the mother.
Placental abruption can begin at any time after 20 weeks of gestation, classically with variable
amounts of vaginal bleeding, abdominal pain, back pain, uterine tenderness and contraction,
and rapid and repetitive uterine contractions.
False labour (Braxton Hicks contractions)
Specifications: Most likely an anatomical model in lieu of a patient.
• Introduce yourself to the patient, and confirm her name and date of birth.
• Explain the examination and obtain consent.
• Indicate that you would weigh the patient, take her blood pressure (pre-eclampsia), dipstick her
urine (pre-eclampsia, gestational diabetes) and ask her to empty her bladder.
• Ask her to expose her abdomen.
• Ensure that she is comfortable.
Carry out a general inspection from the end of the couch.
• Abdominal distension and symmetry. Is the umbilicus everted?
• Foetal movements (after 24 weeks).
• Linea nigra (brownish streak running vertically along the midline from the umbilicus to the
• Striae gravidarum (purplish stretch marks from the current pregnancy).
• Striae albicans (silvery stretch marks from previous pregnancies).
• Enquire about pain before palpating the abdomen.
• Then, facing the mother, determine the:
– liquor volume (normal, polyhydramnios, oligohydramnios)
• Turning to face the mother’s feet, determine the:
Obstetrics, gynaecology, and sexual health
Station 71 Obstetric examination 193
Table 27. Some important obstetric definitions
a longitudinal lie or shoulder/arm for a transverse/oblique lie.
Engagement. During engagement, the presenting part descends into the pelvic inlet in readiness for
labour. Engagement is usually described in fifths of head palpable above the pelvic inlet, although
sometimes the presenting part may not be the head. Engagement usually occurs after 37 weeks of
gestation, before which the foetus is said to be ‘floating’ or ‘ballotable’.
Although not usually performed until labour, indicate that you could also determine the position,
Figure 43. Measurement of station.
Symphyseal–fundal height (SFH)
Using a tape measure, measure from the mid-point of the symphysis pubis to the top of the uterus.
From 20 to 38 weeks of gestation, the SFH in centimetres approximates to the number of weeks of
gestation ± 2 (see Figure 44).
Listen to the foetal heart by placing a Pinard stethoscope over the foetus’ anterior shoulder and
estimate the heart rate (usually 110–160 bpm). Ensure that your hands are free from the abdomen.
194 Station 71 Obstetric examination
• Thank her and offer to help her up.
195Obstetrics, gynaecology, and sexual health
Specifications: You may be asked to circumscribe your questioning to certain aspects of the
• Introduce yourself to the patient, and confirm her name and date of birth.
• Explain that you are going to ask her some questions to uncover the nature and background of
her gynaecological complaint, and obtain consent.
• Ensure that she is comfortable.
Presenting complaint and history of presenting complaint
• Ask about the presenting problems (if any) in some detail, e.g. onset, duration, pain, bleeding,
– date of LMP – did it seem normal?
– inter-menstrual, post-menopausal, post-coital bleeding
– coitus, e.g. “Are you sexually active?” “When was the last time you had sexual intercourse?”
– date and result of the last cervical smear test
– vaginal discharge – for any discharge, ask about amount, colour, smell, itchiness
• Past gynaecological history.
• Past reproductive history: previous pregnancies in chronological order, including terminations
– current, past, and childhood illnesses
196 Station 72 Gynaecological history
• Prescribed medication, including, if appropriate, oral contraceptives and HRT.
• Over-the-counter medication.
• Ask about parents, siblings, children. Has anyone in the family had a similar problem? In the
case of a suspected STD, don’t forget to ask about the partner.
• Ask the patient if there is anything she might add that you have forgotten to ask about.
• Summarise your findings and offer a differential diagnosis.
Conditions most likely to come up in a gynaecological history station
• The permanent cessation of the primary functions of the ovaries, namely, the ripening and
release of ova and the release of hormones that cause both the creation and the subsequent
shedding of the uterine lining. It normally occurs gradually over a period of years during the
• Signs and symptoms may include irregular menses, hot flushes and night sweats, increased
stress, mood changes, sleep disturbances, atrophy of genitourinary tissue, vaginal dryness, and
• The absence of a menstrual period in a pre-menopausal woman for a period of 3 months (or 9
months in women with a history of oligomenorrhoea). It is a sign with many causes including
normal pregnancy, lactation, and oral contraceptives.
• Primary amenorrhoea (menstruation has not started by age 16 or age 14 if there is a lack
of secondary sexual characteristics) is often related to chromosomal or developmental
• Secondary amenorrhoea (menstruation has started but then stops) is often related to
disturbances in the hypothalamo–pituitary axis due to, for example, stress, excessive dieting or
exercising, PCOS, or a prolactin-secreting pituitary tumour; hypothyroidism; certain drugs such
as antipsychotics and corticosteroids; intrauterine scar formation; premature menopause.
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Station 72 Gynaecological history 197
• Severe uterine pain possibly radiating to the back and thighs either preceding menstruation
by several days or accompanying it. Associated symptoms might include menorrhagia, nausea
and vomiting, diarrhoea, headache, dizziness, fainting, and fatigue.
• Secondary dysmenorrhoea is diagnosed in the presence of an underlying cause, commonly
endometriosis or uterine fibroids.
• Abnormally heavy (>80 ml) and/or prolonged (>7 days) menstrual period at regular intervals
possibly associated with dysmenorrhoea and signs and symptoms of anaemia. In many
cases, no cause can be found. However, common causes include hormonal imbalance, pelvic
inflammatory disease, endometriosis, uterine polyps or fibroids, adenomyosis, intrauterine
device, coagulopathy, and certain drugs such as NSAIDs and anticoagulants.
• Bleeding between periods may be associated with sexual intercourse or may occur
spontaneously. Causes of spontaneous inter-menstrual bleeding include physiological
hormone fluctuations, oral contraceptives, cervical smear test, certain drugs such as
anticoagulants and corticosteroids, vaginitis, infection (e.g. chlamydia), cervicitis, cervical
polyps, uterine polyps or fibroids, and adenomyosis. It is particularly important to consider
cervical cancer, endometrial adenocarcinoma, threatened miscarriage, and ectopic pregnancy.
Vaginal discharge (see Station 77)
Gynaecological (bimanual) examination
Specifications: A pelvic model in lieu of a patient.
• Introduce yourself to the patient, and confirm her name and date of birth.
• Explain the examination, reassuring the patient that, although it may feel uncomfortable, it
• Confirm that the patient has emptied her bladder.
• Indicate that you would normally carry out an abdominal examination prior to a gynaecological
• Once undressed, ask the patient to lie flat on the couch, bringing her heels to her buttocks and
then letting her knees flop out.
• Ensure that she is comfortable, specifically enquiring about any areas of pain, and cover her up
Always tell the patient what you are about to do.
• Don a pair of non-sterile gloves and adjust the light source to ensure maximum visibility.
• Inspect the vulva, paying close attention to the pattern of hair distribution, the labia majora,
and the clitoris. Note any redness, ulceration, masses, or prolapse.
• Inspect the perineum, looking for episiotomy scars or perineal tears (fine white lines).
• Palpate the labia majora for any masses.
• Try to palpate Bartholin’s gland (the structure is not normally palpable).
• Lubricate the index and middle fingers of your gloved right hand.
• Use the thumb and index finger of your left hand to separate the labia minora.
• Insert the index and middle fingers of your right hand into the vagina at an angle of 45 degrees.
• Palpate the vaginal walls for any masses and for tenderness.
• Use your fingertips to palpate the cervix. Assess the cervix for size, shape, consistency, and
mobility. Is the cervix tender? Is it open?
• Palpate the uterus: place the palmar surface of your left hand about 5 cm above the symphysis
pubis and the internal fingers of your right hand behind the cervix and gently try to appose
your fingers in an attempt to ‘catch’ the uterus. Assess the uterus for size, position, consistency,
mobility, and tenderness. Can you feel any masses?
Obstetrics, gynaecology, and sexual health
Station 73 Gynaecological (bimanual) examination 199
• Palpate the right adnexae: place the palmar surface of your left hand in the right iliac fossa and
the internal fingers of your right hand in the right fornix and gently try to appose your fingers
in an attempt to ‘catch’ the ovary. Assess the ovary for any masses and for excitation tenderness
• Use a similar technique for palpating the left adnexae.
• Once you have removed your internal fingers, inspect the glove for any blood or discharge.
• Dispose of the gloves and wash your hands.
• Offer the patient a box of tissues and give her the opportunity to dress.
• Ensure that she is comfortable.
• Indicate that you could also have carried out a speculum examination and taken a cervical
smear (see Station 74: Speculum examination and liquid based cytology test).
• Summarise your findings and offer a differential diagnosis.
Conditions most likely to come up in a gynaecological examination station
• Common and often multiple benign tumour of the smooth muscle (myometrium) of the
uterus, typically found during the middle and later reproductive years. In most cases uterine
fibroids are asymptomatic, but in some cases they can cause menorrhagia, dysmenorrhoea,
inter-menstrual bleeding, dyspareunia, urinary frequency and urgency, and fertility problems.
• Functional fluid-filled sacs within or on the surface of an ovary. Ovarian cysts are very
common, particularly in women of reproductive age, and are generally benign and
asymptomatic. Symptoms can include pelvic pain, pain during urination, defecation, or sexual
intercourse, urinary frequency, nausea and vomiting, abdominal fullness, breast tenderness,
Specifications: An anatomical model in lieu of a patient.
• Introduce yourself to the patient, and confirm her name and date of birth.
• Explain the procedure, specifying that it may be uncomfortable but should not be painful.
• Gather the appropriate equipment.
• Confirm that the patient has emptied her bladder.
• Once undressed (from the waist down), ask her to lie flat on the couch, bringing her heels to her
buttocks and then letting her knees flop out.
• Ensure that she is comfortable, and cover her up with a drape.
• Non-sterile gloves • Lubricant (K-Y jelly)
• Bivalve (Cusco) speculum • Cervical brush
• Pot of preservative solution
• Adjust the light source to ensure maximum visibility.
• Wash your hands and don the gloves.
• Inspect the vulva, paying close attention to the pattern of hair distribution, the labia majora,
and the clitoris. Note any redness, ulceration, masses, or prolapse.
• Warm the speculum’s blades in your palm or under warm water (unnecessary with plastic
• Place a small amount of K-Y jelly on either side of the speculum near the tip.
• Tell the patient that you are about to start, and ask her to relax and take deep breaths.
• With your non-dominant hand, part the labia to ensure all hair and skin are out of the way.
• With your other hand, slowly and gently insert the speculum with the screw facing sideways,
rotating it into position (screw upwards) and then opening it.
• Fix the speculum in the open position by tightening the screw.
A smear should not be taken if there is any bleeding or vaginal discharge.
• Insert the central bristles of the cervical brush into the endocervical canal and rotate it by 360
degrees in a clockwise direction five times.
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