obstetric history i
DESCRIPTION
A guide to obstetric clerkship for the student. This presentation deals with a patient who has come with a complaint.TRANSCRIPT
A Guide To ObGyn Case Presentation
OBSTETRIC HISTORY I
For a patient who presents with a complaint
Associate Professor Dr Hanifullah Khan
The importance of a good history
Introduction This section details the key points of a clinical history
The Importance of Patient History
A large percentage of the time, a diagnosis can be made based on the history alone
The critical first step in determining the aetiology of a patient's problem
A carefully taken history – provides a clinical guide for the P/E to follow
2 Purposes
Provide a synopsis of background
risk!
An account of the progress
of the pregnancy
Proper SequenceHistory should be taken & presented in a logical
sequence
Mandatorily, the initial sequence must include !
• CC, HOPI, HOCP & HOPP in that order, !
• although HOPI and HOCP may be combined if required
• Chief complaint!• History of present illness!• History of current pregnancy!• History of past pregnancy
• Gyn/ob history!• Past medical /surgical history!• Family history!• Drug /blood transfusion history!• Social history
The other components!• then follow, but may be
rearranged in order of relevance to the HOPI or HOCP
This is an actual student history
Sample History
always begin with chief complaint
there is only 1 patient history,
although it contains many sections
do not use titles for each
section, instead use paragraphs
The history should be as
short as possible - make
intelligent use of descriptive
words & avoid irrelevant & unnecessary
words. Do not repeat
information
the major portion of the
history should be the history of current illness
!This is an actual student
presentation!!
This is the main reason the patient has come to see you The Chief Complaint
Usually a single symptom, !
occasionally more than one complaint eg: chest pain, palpitation, shortness of breath
The patient describes the problem in their own words
It should be recorded as such
Must have duration of problem!
Short/specific in one clear sentence
• Elaborate on the chief complaint in detail • Ask relevant associated symptoms • Have differential diagnoses in mind
History of Current Illness
1.Demographic info!
2.Primary history !3.Associated
symptoms!4.Symptoms of any
complications
Components of HOCI
• Always relay story in duration (e.g. “the patient was apparently well until 1 day prior to admission”) and NOT time (e.g. last Wednesday or in July)!
• If the patient has > 1 symptom, !• take each symptom individually and !• follow it through fully !• mention significant negatives as well!
• Avoid medical terminology
Components of HOCI!1. Demographic
info!2. Primary
history !3. Associated
symptoms!4. Symptoms of
any complications
Demographic Information
Gravidity - no. of pregnancies!including current pregnancy!(regardless of the outcome)!Parity - no. of births beyond !
24 wk gestation
Name, age , gravidity, parity, LMP, EDD
Appropriate to begin with a summary of the details
*Actual student history - grammar, context and other features can be improved!
Components of HOCI!1. Demographic
info!2. Primary
history !3. Associated
symptoms!4. Symptoms of
any complications
Primary History
Elaborates on the main complaint & deals with the chronology & the characteristics
of the chief complaint
Describes the onset, course, severity and duration of the chief
complaint
Some features of the 10 Hx!• Anatomic location!
• Quality!
• Quantity or severity!
• Timing!
• Setting in which the symptoms occur!
• Aggravating or relieving factors
Note that not all questions may be relevant for a symptom, e.g. a location cannot be determined for “difficulty in breathing”
Components of HOCI!1. Demographic
info!2. Primary
history !3. Associated
symptoms!4. Symptoms of
any complications
Associated Symptoms
May serve as a general review of systems
Information gathered here serves to: !
• support the diagnosis !• gauge the severity of the
disorder
Examples
❖ if a pt ℅ abdominal pain - must ask for presence or absence of nausea and vomiting!
❖ if a pt ℅ vaginal bleeding - per vaginal discharge, pruritis or
Components of HOCI!1. Demographic
info!2. Primary
history !3. Associated
symptoms!4. Symptoms of
any complications
Symptoms of Complications
This will help in the subsequent management
of the pt
Again, this helps to confirm the diagnosis & assess the severity of the problem
Examples
For complaint of dysuria & increased frequency of micturition - loin to
groin pain, backache & fever; might suggest ascending infection
complicating the UTI
The Complete HOCI
Please do not forget this…
REMINDER!!
The most elaborate and largest component of a patient history is the history of current
illness.!!
All other components should be concise and serve as supportive information for the
history of current illness.!
Antenatal history or…
History of Current Pregnancy
In which you assess the status of the current pregnancy and its connections to the current illness
The HOCP
Should have a !few components
Should be a chronological & concise account (1st, 2nd & 3rd trimesters)
Confirmation of pregnancy
Comorbidities
Results of ultrasound scans
Antenatal booking & results of tests
1. Confirmation of pregnancy
❖ assessment of menstrual period!
❖ urine pregnancy test (UPT)!
❖ assessment of symptoms!
❖ early ultrasound scan
This can be done in a number of ways
Calculation from LM
Assessment of menstrual periodAccuracy is reliant on a few points:!• must be measured using 1st day of LMP!• periods must be regular of 28 day cycle!• the pt must be sure of the LMP!!Calculation of dates is inaccurate if any of these conditions are unfulfilled
The gestational date can be calculated from the last menstrual period (LMP) using Naegele’s rule
Urine test
UPT
Subjective test - it doesn't quantify gestation but may suggest the duration of pregnancy!!Not very specific nor sensitive - false positives are common
Becomes positive around 5 weeks of gestation
The occurrence of pregnancy symptoms…
Assessment of Symptoms
Quickening - the first sensation of fetal movement :!
primigravida - felt between 22-23 weeks!multigravida - felt between 16-18 weeks
may indicate the gestation & provide a rough guide to the accuracy of the menstrual dates
Common early pregnancy symptoms are nausea, vomiting,
gastric symptoms & general malaise:!
noticeable between 5-6 weeks gestation!
usually quite accurate!absence of symptoms is not
predictive of feral well-being
These symptoms become important to confirm gestation
if an early ultrasound scan was not done
Done within the first 12 weeks of gestation…
Early Ultrasound ScanEvery early scan must answer at least 3 questions - the number of fetuses, their health (viabilty) & the gestation!!A simple scan is used to measure the Crown-Rump Length (CRL) for accurate dating!!Always ask the patient if she has had one & confirm the above 3 questions
provides the most accurate assessment of gestational dates. Every mother should be encouraged to have one.
2. Antenatal booking & results of tests Determine precisely!❖ the booking Haemoglobin (Hb)
- the occurrence of physiological anaemia in later trimesters masks the actual blood content!
❖ the booking Blood Pressure (BP) - this is to determine if the patient has preexisting hypertension (H/T)!
❖ if screening for diabetes mellitus (DM) was done & the results
Early booking - important to determine the initial well being of the mother as
well as for assessment of potential risks!The 1st trimester is the time when the patient is closest to the non-pregnant
state!Subsequent hormonal & physiological
alterations tend to mask findings & may confuse patient assessment
Other antenatal tests - Hepatitis screen, VDRL, HIV - should just be mentioned as normal & need not be
elaborated
3. Results of ultrasound scans❖ The early u/s scan is
considered the gold standard for fetal dating!
❖ The 2nd trimester u/s scan - assessment of feral anomaly!
❖ 3rd trimester scan - placental site, confirm lie & liquor & size
It is important to ask the pt about any scans done!
An early scan is one done prior to 14 weeks
gestation
Ultrasound scanning is part & parcel of modern obstetric practice. All
mothers should have access to this
4. ComorbiditiesThe commonest are DM &
Hypertension (H/T)!The incidence of preexisting disease is increasing & it is common to find
mothers getting pregnant with them
Other important comorbidities include anaemia & thyroid disease
❖ Late pregnancy disease usually affects growth & well-being
❖ Differentiation between early & late pregnancy disease is crucial!
❖ Early pregnancy disease has implications on fetal development
This is a sample of the HOCP. It should not be too long and contain all the necessary information.
Confirmation of pregnancy
Investigations during booking
Ultrasound scans Screening for comorbidities
Previous pregnancies and deliveries …
History of Past Pregnancy (HOPP)
What happened in the past may indicate the cause of the current problem as well as impact the current pregnancy
Summarize significant points❖ Any significant ante-, intra-
or postpartum events!❖ miscarriages & their
outcomes!❖ Life & health of the baby!❖ Contraception – Type,
when begun, why stopped, any side effects!
❖ Did the current complaint occur in past pregnancy?
Not necessary to present everything!
An early scan is one done prior to 14 weeks gestation
❖ Modes of delivery, baby gender & birth weights need not be presented individually
This student has combined the gynae/menstrual history with HOPP,
perfectly acceptable & useful
Additionally, breast feeding (BF) should be asked for, &
reinforced as a positive attitude
BF is also significant, as many women have amenorrhoea or
abnormal periods due to hyperprolacinaemia which may
impact the accuracy of dates
All the other stuff
Other components These components provide supportive evidence for the possible diagnosis
Remember this?History should be taken & presented in a logical
sequence
Mandatorily, the initial sequence must include !
• CC, HOPI, HOCP & HOPP in that order, !
• although HOPI and HOCP may be combined if required
• Chief complaint!• History of present illness!• History of current pregnancy!• History of past pregnancy
• Gyn/ob history!• Past medical /surgical history!• Family history!• Drug /blood transfusion history!• Social history
The other components!• then follow, but may be
rearranged in order of relevance to the HOPI or HOCP
The last part of the history
Rearranged according to relevance
These histories support the HOCI!
!They should be brief!
!Questions asked the patient
should be relevant to the current problem or associated
with the management
• Gyn/ob history!• Past medical /surgical history!• Family history!• Drug /blood transfusion history!• Social history
The rest of the component histories are arranged
according to their relevance to the patient’s problem
An example
This is an abbreviated example of the other histories with relevance to the patients problem!
!Some questions such as family history of diabetes and hypertension are
universal - they are relevant irrespective of the complaint due to the global impact of the disease!
!Socioeconomic history serves to elaborate the status of the patient with
particular relevance to communicable disease!
Most people consume alcohol but are not dependant on it; it
is wrong to use the term alcoholic ulnless there is
evidence of substance abuse
This is the HOCI!This should be the largest component
of the history
This is the HOCP & HOPP!
This should follow the HOCI
The other histories!
Make up the smallest portion of the full history
Any component history that is contributory to the diagnosis and significant, should be made part of the HOCI
Happy Clerking!