History taking in obstertrics
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Transcript of History taking in obstertrics
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History Taking in ObstetricsKavya Liyanage
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Main Topics
• Demographic history• About this pregnancy• Ultrasound scan• Past obstetric history• Gynecological history• Past medical and surgical history• Psychiatric history• Family history• Social history• Drug history• Allergies
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Demographic history
⚫Name⚫Age⚫Occupation⚫Ethnic background⚫Presenting complaint or reason for attending
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About this pregnancy
⚫Gestation
⚫Last menstrual period (LMP)
⚫Estimated date of delivery (EDD)
⚫Dates as calculated from ultrasound
⚫Single/multiple (chronicity)
⚫Details about presenting complaint
⚫What actions are taken?
⚫Is there any plan for the rest of the pregnancy?
⚫What are the patient’s main concerns?
⚫Have there been any other problem in this pregnancy?
⚫Has there been any bleeding, contractions or loss of fluids vaginally?
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Ultrasound
⚫What scans have been performed?⚫Why?⚫Were any problems identified?
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Past obstetric history
⚫Were there any previous pregnancies?⚫If were, their outcomes in order
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Gynecological history
⚫Regularity of periods⚫Contraceptive history⚫Previous infections and their teatments⚫Previous cervical smear performed and their
results and if any, treatments⚫Previous gynecological surgery
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Past medical and surgical history
⚫Relevant medical problems⚫Any previous operations; types of anaesthetic
used and any complications
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Psychiatric history
⚫Postpartum blues or depression⚫Depression unrelated to pregnancy⚫Major psychiatric illnesses
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Family history
⚫Diabetes⚫Hypertension⚫Genetic problems⚫Psychiatric problems
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Social history
⚫Smoking/ alcohol/ drugs⚫Marital status⚫Occupation, partner’s occupation⚫Help at home⚫Housing problems
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Drug history
⚫All medication including over-the-counter medication⚫Folate supplementation
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Allergies ⚫Any allergies⚫What problems do they cause?
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Thank you!