HISTORY TAKING Obstetric Case
Overview
Taking a history and performing an obstetric examination are quite different from their medical and surgical equivalents. Not only will the type of questions change with gestation but also will the purpose of the examination
Etiquette
Always lways
introduce yourself; tell the patient who you are and say why you have come to see them. Sensitive to intensely privat pri vate e data. Some women will wish another a nother person (chaperon) to be present if the doctor or students is male, even just to take a history, and this wish should be respected.
Components of History Taking 1. Demo Demogr grap aphi hicc Dat Data: a) Name to build rapport and reflects good bedside bedsi de manner m anner.. b) Age as a general rule, the very young (<18 years) and the elderly (>35 years) are more likely to be associated with problems. c) Occupation - this would would give give us us an idea idea of the social class of the patient. d) Race
2.
Histo History ry of Curr Curren entt Preg Pregan anan ancy cy
a) Gra Gravida ida - tot total num numbe berr of pr pregna egnanc ncy y reg regar ardl dles esss of how they ended. b) Parity arity - is the the numb number er of live live birt births hs at any any gestation gestation or stillbirths stillbi rths after 24 (?) weeks. c) EDD: Naegele Naegeless rule [EDD [EDD = (LMP + 1yr + 7dys) (3 mths). Applied for: 28 day cycle, regular, no recent use of OCP. Ultrasound BPD, AC*, FL, HC Gestation Calculator (Wheel) d) Singleton/Multiple fetus fetus
3.
Antenatal History a) Menarche b) Cycle Cycle Regu Regular larity ity (28(28-30 30 da day) c) Duration of Me Menses e.g. 7 day with 3 heavy flow, d) Pads used e) Plan Planne ned d / Unp Unplan lanne ned d preg pregna nanc ncy y f) Booking date of booking started Test results: result s: Ht, Wt, BP, VDRL, TPHA, HIV, HepB, ABO, Rh, FBC, Hgb, etc. Numbers of check-up attended where? Eventful? CTG? Earlier & Latest USS when? What finding?
4. Present Complaint
a) Reaso ason adm admitt itted b) Test do done
Problem must must be listed in priority if i f there are multiple problems and explained concisely and adequately. adequately. Common problems: UTI, HPT, GDM, Antpartum ntpartum hge., hge., twins, leaking liquor, liquor, etc.
5.
Past Obstetric History a) Prev Previou iouss Pregn Pregnanc ancy y (first (first to lates latest) t) b) Mod Mode of deli deliv very ery SVD, CS c) Alive or Well? d) Term erm of pr pregna egnanc ncy y pre, term, post e) Termina ination ion abortion, miscarriage f) Weight range g) Plac Place e of of de deliv livery h) Complic licatio tion mother? Child? i) Singleton? Twins ins?
6.
Past Past Gynaecolog Gynaecological ical History History
a) Proc Proced edur ure e und under ergo gone ne b) Gynec ynecol olog ogic ical al prob proble lem m c) Contraception d) Dysp Dyspar areu euni nia a (e.g. (e.g. vagin aginas asmu mus) s) e) Cervic Cervical al examin examinatio ation: n: e.g. Pap Smear Smear
7.
Past Medical & Surgical History
a) Histo History ry of: of: HD HD, Epilep Epilepssy, BA, HPT, DM, Thyroid disorder, TIA. b) Surgery anaesthetic, complication c) Imm Immunization ion d)
Allergic
e) Medication
8.
Family History
a) Complic Complicat ated ed pregn pregnanc ancy y and and delive delivery ry b) Twins c) Healt alth conditio ition n HPT, BA, DM etc.
9.
Social History
a) Marit Marital al sta tatu tus* s* - single single,, div divor orce ced, d, mar marrie ried, d, partnership, medicolegal. b) Occupation c) Vices alcohol, smoking, illicit drugs.
Summary Madam X is a 28 year old housewife, gravida 3, para 2 and presently at 34 weeks maturity. She is sure of her dates. She presents with the problem of one, hypertension in pregnancy that was first detected at 28 weeks, two, a history of previous caeseran section for placenta praevia and three, symptoms suggestive of urinary tract infection. There is no past medical or surgical history of note.
