My notes: Its How I graduated Medical School.: Complete Obstetrics history (points not to be missed)

Tuesday, March 15, 2016

Complete Obstetrics history (points not to be missed)

1. Patients Particulars 2. Chief Complain 3. Menstrual History 4. Obstetrics History a. Marital History b. Parity Index (GxPxAxLx) i. Antenatal ii. Natal iii. Post Natal c. Abortion d. Contraceptive history 5. History of Present pregnancy a. First Trimester i. ANC visits ii. Complains iii. Complications b. Second trimester i. ANC visits ii. Complains iii. Complications c. Third trimester i. ANC visits ii. Complains iii. Complications 6. History of Present illness 7. History of Past Illness a. Chronic medical illness b. Past diseases c. Surgery d. Drug and Allergy History : 8. Personal History 9. Family History 10. Socioeconomic History

List of items in Obstetrics history

This page is dedicated to writing history of a Obstetrics case for medical students.

The following points should always be included in any obstetrics history. These form the basis of Obstetrics history. The patient particulars followed by the presenting complains are the first things to be listed. Unlike any other history writing, obstetric history doesn't have history of present illness immediately after the chief complains. The menstrual and obstetrics history gets the priority ahead of that. Similarly, history of present pregnancy must be included before the elaboration of presenting complains because menstrual, obstetrics and history of present pregnancy is the basis of history writing in any obstetric case.

Last Menstrual Period dd/mm/yyyy Expected Date of delivery dd/mm/yyyy Period of gestation: from the LMP (9months and 7 days from the LMP) Menarche Regularity of cycles and its length Duration of menstrual flow Passage of clots Dysmenorrhea Number of pads changed per day and its soakage.

Menstrual History : Points to include

Learn about the indications of Cesarean Section

A. Marital History Duration of marriage Age at marriage B. Parity Index (GxPxAxLx) Gravida Para Abortion and Living (in order) Age at first conception and child birth For every Parity (if not eventful) Sex of baby, age of baby, mode of delivery and place of delivery with birth weight if feasibleIf eventful 1. Antenatal Visits, Intake of folic acid, iron and calcium, any unusual events : Gestational Diabetes Mellitus, Elevated BP/ Preeclampsia/Eclampsia, Antepartum Hemorrhage, IUGR, Fetal anomaly on scan, or any other complication 2. Natal Period of gestation, Premature rupture of membrane, Antepartum hemorrhage, duration of labor, induction of labor, failure of progression of labor if caesarean section done : indication for caesarean, no of times CS done, Type of Scar in the abdomen, Scar tenderness or any other complication 3. Post Natal Mother Post partum Hemorrhage, vulval hematoma, urinary retention, wound infection, fever or any other complication Baby Birth weight, Baby cried immediately after birth, passage of meconium, passage of urine, Breast feeding, need for ICU stay, fever, or any other complication C. Abortion How long back? Period of gestation? Spontaneous or induced? if induced medical termination or surgical? If aseptic where ? history of fever, PPH, Molar pregnancy or any other complicationD. Contraceptive history Duration of use of contraception Indication for initiation Indication for termination Any complication If any incidence of failure and alternatives used

Previous Obstetrics history: Points to be included

Learn more about the parity index. Para, Gravida, Living and Abortion and solve some problems.

First Trimester Confirmation of pregnancy by UPT after ? Cessation of menstruation. 1. ANC visits Frequency Weight and height If yes Blood test (ABO Rh Typing, Serology, and Blood Sugar) Urine test (UPT, URME) Ultrasonography done or not Use of Folic acid (mention if pre-conceptional) 2. Complains Urinary Complains: Urgency, frequency and burning micturitionGastric Complains: Nausea vomiting and altered taste Breast Complains: Enlargement of breast, soreness of breast, darkening of areola Vaginal Complains: PV discharge, itching 3. Complications Fever, pain abdomen or PV bleeding Need of Hospitalization for any of the complains Exposure to radiation Intake of any drug

History of present pregnancy: things you need to ask in 1st trimester

Continuation of cessation of menstruation Abdominal distension with enlargement of breast and areolar tissue Weight gain Quickening felt at 1. ANC visits Frequency Intake of iron Intake of calcium Intake of Albendazole Two tetanus toxoid vaccination Glucose challenge test Anomaly Scan 2. Complains Urinary Complains: Urgency, frequency and burning micturition Gastric Complains: Nausea vomiting and altered taste Breast Complains: Enlargement of breast, soreness of breast, darkening of areola Vaginal Complains: PV discharge, itching 3. Complications Pain Abdomen PV bleeding PV discharge Fever Body edema, headache, epigastric pain, dizziness, blurring of vision Shortness of breathe Need of hospitalization for any of the cause.

History of present pregnancy: things you need to ask in 2nd trimester

Continuation of cessation of menstruation Abdominal distension with enlargement of breast and areolar tissue Weight gain Perceiving fetal movement 1. ANC visits Number of visit Intake of iron Intake of calciumUSG at 3rd trimester 2. Complains Urinary complains Respiratory complains Pedal edema 3. Complications Pain Abdomen PV bleeding PV discharge Fever Body edema, headache, epigastric pain, dizziness, blurring of vision Shortness of breathe Need of hospitalization for any of the cause.

History of present pregnancy: things you need to ask in 3rd trimester

Elaborate the presenting symptoms to support your provisional diagnosis, rule out the differential diagnoses with negative history and always rule out the complications associated with these problems in the history of present illness. And identify any other symptoms present that may support your diagnoses from any other systems in the body.

Elaboration of the presenting complain Positive history (To support provisional diagnosis) Negative history (To rule out differential diagnoses) History to rule out complications Systemic review

Things to elaborate for the presenting complains.

Past history, Personal history, family history and socio-economic history are equally relevant and important in any history taking and so does in obstetrics.