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History Writing: A case of Premature rupture of Membrane

(All the patients may not have the same symptoms at presentation and the same risk factors, so history taking should always be INDIVIDUALISED than generalised to a standard sets of check list.It is always RECOMMENDED to ask the patient their problems and the question associated with the problem as per the need.

Interpersonal variations are always exists in the way the history is taken and written. Pattern, format and style of history taking and presenting are subject to change as per institutional protocol and region.Please kindly follow the system that is acceptable in your context.)

>>All the points that should not be missed while taking a Obstetrics History.

Patients Particulars (to be enlisted rather than written in text)

Name: Sita Koirala

Age: 28years

Address: Dhulikhel

Religion: Hindu

Marital status: married to Ram Koirala

Married for 7 years

Occupation: Housewife

Date of admission: 2016/03/05

Place of presentation: Emergency Department

Date of examination: 2016/03/07

(Mrs Sita Koirala, 23 years lady, a housewife from Dhulikhel, married for 7 years, presented to DH emergency with)

Complain of

Cessation of menstruation for 8 months

Pain abdomen for 1 day

PV leak for 3hrs

Menstrual History

Last Menstrual Period 2015/07/01

Expected Date of delivery 2016/04/07

Period of gestation: 36 WOG

Menarche: 13 years

Regularity of cycles and its length: Regular every 28 days

Duration of menstrual flow 3-4 days

Passage of clots (-)

Dysmenorrhea (-)

Number of pads changed per day and its soakage.(3 pads/day, partially soaked)

(She attained her menarche at the age of 13 years with regular cycles of 28 days and menstrual flow of 3-4 days. She changes 3 partially soaked pads per day with no history of passage of clots and severe crampy pains during her menstruation)

Obstetrics History

Marital History

Duration of marriage 7 years

Age at marriage 21years

Parity Index (G3P1A1L1)

She is a Gravida 3 Para 1 Abortion 1 and Living 1 lady and was 23 years at the age of her first child birth.

She has a 5 years old boy, delivered normally at Dhulikhel Hospital with birth weight of 2.8 kg. Antenatal, natal and postnatal period was uneventful.

She had a spontaneous abortion 1 year back at 10 weeks of gestation for which she underwent suction and evacuation at Dhulikhel hospital. No complications were noted.

Contraceptive history

She used OCP immediately after her marriage but discontinued after 3 cycles of use. 3 months after the delivery of her child she inserted cupper T. She removed copper T one year back. She had regular cycles during the use and no complications were noted in between.

History of Present pregnancy

First Trimester

She confirmed her pregnancy after 1.5 months of cessation of menstruation at local clinic by urine pregnancy test. She had complains of nausea and vomiting but was not severe enough to get hospitalized. She also complains of urgency and frequency but no burning micturition. Mild soreness of breast was present. But she does not give history of fever, pain abdomen or per vaginal bleeding.

She had 1 ANC visit in the 1st trimester where her blood and urine examination was done and was told to be normal. She took Tab Folic acid. USG was not done. No exposure to any radiation or intake of any other non-prescribed medication.

Second trimester

Cessation of menstruation continued. There was progressive enlargement of abdomen and breast.

Quickening was experienced at 5 months of gestation.

She had 3 ANC visits. She had routine checkup and was told to be within normal limits. She took tab iron and tab calcium regularly. Tab Albendazole was taken at 5th month of gestation. 2 doses of TT vaccination was taken month apart. Blood test after consumption of glucose and water was done which was told to be normal. USG was done at 5th month and told to be normal.

She had no complains of urgency, frequency and burning micturition. No complains of headache, blurring of vision, shortness of breath. No history of fever, PV bleeding or PV discharge.

Third trimester

Cessation of menstruation continued. There was progressive enlargement of abdomen and breast. She gained a total weight of 10 kg during her pregnancy. She is perceiving fetal movements.

She had 4 ANC visits, continued the intake of tab Iron and calcium.

No complains of urgency frequency, No swelling of limbs and shortness of breath. No complains of headache, blurring of vision, fever, PV bleeding or PV discharge.

History of Present illness

According to the patient she was apparently well 1 day back, then she gradually developed lower abdominal pain which was insidious on onset, on and off. No radiation of the pain. No aggravating and relieving factors were present. She also gives history of per vaginal leaking 3 hours back which was plenty enough to soak her clothes which aggravated her abdominal pain. The fluid was clear and not stained with blood or green colored discharges.

She is perceiving fetal movement.

She does not give history of PV bleeding.

No history of fever, no urgency frequency or burning micturition.

No PV discharge.

No history of nausea, vomiting, diarrhea or abdominal distension.

No history of trauma.

No cough, cold or chest pain.

History of Past Illness

No history of chronic illness like Hypertension, Diabetes Mellitus, Epilepsy, Rheumatic Heart Disease, Bronchial Asthma, or Hypothyroidism. No past history of tuberculosis or jaundice.

No prior surgeries done. Not under any medication for any chronic illness.

No known allergy to any food, drug or other substances.

Personal History

She is a non- smoker and does not consume alcohol. She consumes non vegetarian diet. She has normal bowel and bladder habit and has adequate rest.

Family History

No history of chronic illness in the family. No history of congenital anomaly in the family. No history of consanguinity. No history of multi-fetal pregnancy or recurrent abortion in the maternal lineage.

Socioeconomic History

She belongs to a well sustained middle class family with good relation in the society. She has completed class 12.She lives in a modern house with good provision of clean drinking water and sanitary latrine.

My Provisional diagnosis based upon history is

G3P1A1L1 at 36 WOG with Premature Rupture of Membrane.

Have problem with gravida para. Try some problems 

*** Disclaimer : This is a hypothetical case and is not a real life scenario. However, the condition is so common and prevalent, it is a coincidence if it matches with the life of any. This case is solely for educational purpose with no intentions meant otherwise.***