Monday, February 23, 2009

Obstetrics: History taking

Obstetrics: Science and art of dealing with a pregnant female.

Obstetrics: History Taking

Name:

Husband’s Name:

Time since marriage:

Gravida:

Parity:

LMP:

EDD:

Presenting Complaint:

- Gestational age in weeks

- Reason for coming today?

History of Presenting Complaint:

- Was the pregnancy planned and spontaneous?

- How did she know she was pregnant?

- How did she confirm the pregnancy?

1st Trimester

- Ask about nausea? vomiting?

- Other associated symptoms such as fever? Abdominal/pelvic/back pain? Burning micturition?

- Vaginal discharge?

- Bleeding per vaginum?

- Use of folic acid tablets? (small yellow colored pills)

- Was an ultrasound done at 6 or 7wks (Dating scan)

2nd Trimester

- Ask about regular use of folic acid, iron and calcium supplements?

- Ultrasound at 18-22wks (Anomaly scan)?

- Quickening: fetal movements? (normally felt around 20 weeks gestation)

- Fever? Rash? Abdominal pain?

3rd Trimester

- Tetanus toxoid vaccine at 28 wks and 32 wks?

- Regular doctor checkups?

- Ultrasound?

- Booked case?

Post-natal History:

- Are you breast feeding the baby?

- Have you passed feces and urine?

- Ask about lotia/bleeding?

- How is the baby doing?

- How is the mother doing?

Past Obstetrics History

  1. Pregnancy:

- Gestational age at time of delivery?

- Outcome of preganancy?

  1. Labour/delivery:

- Normal vaginal delivery? C-section?

- Labor- Normal? Prolonged?

- Length of labor?

- D&E?

- D&C:

- Place of delivery? (at home or at the hospital?)

- Any other complications?

  1. Perperium:

- Any complications?

  1. Baby:

- Gender of baby?

- Age of baby?

- Breast fed? Length of breast feeding?

- Birth weight?

Menstrual History:

- Age at menarche

- Cycle

- Flow

- Dysmenorrheal?

- Intermenstrual bleeding?

- Post-coital bleeding?

- Contraceptive use?

- Has she ever had a PAP Smear taken?

- LMP

Past History:

- Past medical: HTN, Diabetes, TB, Seizures, Asthma etc..

- Past Surgical

- Blood Transfusions

- Is her vaccination up-to-date?

Personal History:

- Appetite

- Sleep

- Bowel

- Micturition

- Recent weight gain/weight loss

- History of any addictions (such as smoking, naswaar, hooka etc..)

- History of any allergies to foods or medicines?

Family History:

- Is the marriage consanguineous?

- History of breast cancer, ovarion cancer, uterine cancer etc..

- History of HTN, Diabetes etc..

Social History:

- # of family members

- # of earning members

- Approximate income?

- Use of boiled water at home?

Posted by Ayesha Zia
Categorized as:

7 comment(s):

  1. very productive blog
    thanks for it
    here i would love to share a website about
    tubal health and women health
    Tubal Ligation Reversal
    ReplyDelete
  2. very helpful!
    thank you
    ReplyDelete
  3. i want to say thank to you because it is very helpfull for me.
    ReplyDelete
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    A tubal reversal is a procedure to reconnect the fallopian tubes in a woman who has previously undergone surgical sterilization, known as tubal ligation. In a tubal reversal operation, the surgeon removes the portion of each fallopian tube that has been blocked or cut. Once the damaged portion has been removed, the tubes are reconnected to form a complete, open fallopian tube.
    ReplyDelete
  6. Feeling nice to be here...
    great job you are doing here...
    i like it..
    ReplyDelete
  7. hi
    thank you for your effort.
    this was helpful
    i would like it if you could clarify what is the significance of asking about the "Use of boiled water at home?" ?!!!! you wrote this under social history .
    thanks again.
    ReplyDelete

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