Obstetrics - History Taking

Patient Identification
Name
Age years old
Ethnic
Sex Female
Occupation
Address

Date of admission
Date of clerking
Informant

Gravida
Para
Abortion

LMP Present as POA

REDD (Revised EDD) (U/S) Present as POG
EDD LMP + 7d - 3mth + 1yr
POA Count from LMP
Present as weeks, days
1 mth = 4w + 2d
2 mth = 8w + 5d
3 mth = 12w + 1w

Chief Complain (complain + duration)

with know case of HPT/hx of ectopic pregnancy/miscarriage ---- year ago at 2015. complete miscarriage? D&C done?

History of Presenting Illness (HOPI)

Is patient in labour? Show-blood stained mucus passed PV | Leaking liquor | Contraction pain (regular)
If symptoms present Fetal movement | What is done in hospital? fever? UTI? (esp in first trimester)
History of Presented Pregnancy (HOPP)
Suspect pregnancy Why? Missed period
Quickening
Abdominal distention
When?

Confirm pregnancy When?

Where?
Who?

Booking When? (Red Card)

(1st antenatal checkup) Where?
Height cm
Weight kg
BP mmHg
Fundal height cm
Blood group (Rh)
Hb
Urine glucose
Urine protein
VDRL Reactive/ Non-Reactive
HIV
HIV / Hep B
Subsequent Attend all ANC follow schedule? How many follow up?
antenatal checkup (ANC) Monthly till 28w
Fortnightly till 36w
Weekly till delivery
Normal parameters? Weight gain
BP Range common: PE in primigravida
Uterine size Ask if the size correspond
to date
Hb
Urine glucose, protein
Ultrasound done? When? How many U/S done?
11-14w for correct dating Abnormalities? (state)
20-24w to detect congenital abnormalities

Quickening When? U/S comment on:

(1st fetal movement) ↑ Intensity, Frequency? 1. fetus -single/multiple/presentation/lie

Primagravida - 18-20w (5mth) -FHR
Multigravida - 16-18w (4mth) -fetal growth
-fetal abnormalities
Signs & Symptoms Nausea, vomiting 2. placenta -placenta abnomalities
of Pregnancy Breast discomfort/ engorgement -> tumour (huge placenta)
Frequency -> retroplacental clot

Constipation (abruptio placenta)

Ankle edema 3. liquor - adequate/reduce

Backache
4. uterus

Immunization Anti-tetanus toxoid (ATT) primi (2X: at 22-24w & 24-28w)

Hepatitis B (3X) multi (1X)

Rubella (usually in school)

Past Obstetric History (POH) (not required if primigravida)
Marital status When married?
Married at age?
1st married? The only married?
Consanguineous married?

No of children boys girls

For Each Pregnancy (1-4 children)

Age
Sex
Where deliver?
When? Full term? POG if preterm?
Method of delivery
Birth weight (Normal - 3.5-4kg)
Complications (antepartum, intrapartum, postpartum)
Breastfeed till? (Normal - 2yr, if early/ bottle feeding - why?) exclusive?
If all deliveries are normal - summarize - no AP, IP, PP Cx (at end of presentation of POH)
normal development stone?
Abortion POG?
(how many?) Why?
Signs, symptoms before abortion
Dilatation, curettage (D&C) done?
D&C - incomplete abortion | No D&C - complete abortion

For Each Pregnancy (If >5 children)

Any uneventful deliveries? FTSVD with no Cx
Age of eldest child
Age of youngest child
Birth weight (range)
Breastfeeding
Mention abnormal deliveries separately

Spacing Good (> 2 years apart)

Abnormal (> 6 years)
Why? Contraception? Subfertility?

Contraceptive Method OCP/ Injection/ Implantation

(Yes? No?) IUDC
Condom
Others

Menstrual History
Menarche (1st menstrual) years old Normal - 9-16 y/o
Menstrual cycle Regular/ Irregular
Cycle Normal - 21-35d
Flow Normal - 2-8d
Heavy flow Normal - 1st-3rd day
Pad used (volume) Normal - 30ml
Past Gynaecology History
Problems
Dysmenorrhoea (painful)
Menorrhagia (prolonged, increased, >80ml)
Intermenstrual bleeding
Postcoital bleeding
Dyspareunia (painful coital)

Pap smear How many times?

When was last one?
Result normal?

Past Medical & Surgical History

History of Chronic Illness Hypertension
DM
Heart disease
Asthma
TB

Any surgery?

Family History

Personal & Social History

Education level
Husband's age, occupation, income
House condition
How frequent husband visit?
Who take care of children during admission?
How does she contact her children?
Smoke/ Alcohol? (patient, husband)

Drug History
Iron
Folate
Vitamin B12, C
Over-counter drugs
Traditional med.
Allergy

Dietary
Adult diet
Allergy
If diabetic, details required - dishes for every meals

Summary
Age, Gravida, Para, POA, Chief Complain
Systemic Review
Respiratory SOB
Night sweat
Fever
Cough
Haemoptysis
CVS Hypertension
Ankle swelling
Chest pain
Palpitation
Musculoskeletal Muscle pain, joint pain
Deformity
Muscle wasting
CNS LOC
Paralysis
Tremor
Drowsiness
Headache
GIT LOW
LOA
Abdominal pain
Pain in swallowing
Vomiting
Nausea
Hematemesis
Diarrhoea
Constipation
Endocrine Swelling in neck
Diabetes mellitus