(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.)
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
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.***
