History taking

1) Patient Profile
Name
Age Race Religion
Residence
Occupation
Gravida Parity Abortion
LMP EDD POA
Admitted date

2) Chief complaint + Duration






3) History of present illness
c/o



Pd



Dd




s/s




Severity
Mild/ moderate/ severe

Medication



Risk factors



Causes



Remarks






4) History of present pregnancy
1st trimester
Booking

Minor ailment


Bleeding

Physical Examination Height Weight BP
Investigations
Hb Urine routine
Bloog group MOGTT
Hept. B HIV VDRL
Ultrasound (Dating scan)

Medications? (vit, iron
tablets, folic acid..)


Remarks
(Planned/Unplanned)



2nd trimester
Minor ailment


Bleeding
Physical Examination
Height Weight BP
Uterine size
Quickening

MOGTT

Ultrasound (Anomaly
scan)

Nuchal thickness :
Development of illness

Tetanus toxoid

Remarks



3rd trimester
Minor ailment
Bleeding
Physical Examination
Height Weight BP
Uterine size
MOGTT
Ultrasound
Remarks




6) Past obstetrical history
G Year
Pregnancy
(Full / Pre)
Type of labour
(SVD, LSCS,
Vacuum, etc...)
Antenatal period
complication
Health of baby
(G, Weight,
A/D)
Breast
Feeding
Remarks












7) Menstrual history
Menarche :
Menstrual cycle : Regularity : Regular / Not
Duration of flow :
Cycle length :
Contraceptive History :
8) Gynaecological history
History of suggestive STI :
Any gynaecological problem :
Past medical history :
Past surgicall history :
Family history :Maternal
Paternal
Siblings
9) Personal history
Diet history :

Vegetarian / non vegetarian
Sleep :
Bowel bladder habit :
Social history : Marital status :
Spouse :
Occupation :
Education :
Income :
Basic needs :
Drug history :
Any allergic ( )
Traditional Medication ( )
Smoking/Alcohol :

Others
Physical examination
General examination
Remarks
Built Small /average/ large
Nourishment Thin / obese
BMI
Weight:
Height:

Vital parameters BP
Temp
Eyes Pallor Icterus
Mouth
Pallor Icterus Oral hygiene
Bleeding in teeth and gums
Neck Thyroid enlargement
Hand & Nail
Finger clubbing

Nail colour

Capillary filling time

Koilonychia/ platynychia
IV Cannula / IV fluid
Breast
Leg Varicose vein Edema
Remark




Systemic examination
1) Cvs : Pulse rate :
Heart rate :
Heart murmur :
Blood pressure :
Heart beat : normal / tachycardia / bradycardia
2) Respi : Respiratory rate :
Breathing :

Abdominal examination
1) Inspection
I. Abdomen distended by gravid uterus ( )
II. Evidence of linea nigra ( )
III. Stretch mark
a. Stria gravidarum ( )
b. Stria albicans ( )
IV. Scars : site :
Size :
Healing :
Hernia to scar :
V. Umbilicus : Inverted ( ) Everted ( )
VI. Fullness of flank :
VII. Fetal movement :
VIII. Quadrant movement :

2) Palpation
I. Enquire of pain :

II. Superficial palpation :

III. Clinical fundal height :

IV. Leopolds maneuvers
a) Fundal grip :

b) Right Lateral grip :

c) Left Lateral grip :

d) 1st pelvic grip :

e) 2nd pelvic grip :

A. Fetal Head Hard globular mass / Hard globular mass which is ballotable suggestive of fetal head.
B. Fetal Breech Broad smooth irregular mass suggestive of fetal breech.
C. Fetal Back Smooth curved broad surface suggestive of fetal back.
D. Fetal Limbs Small irregular knob like sturcture suggestive of fetal limbs.

3) Auscultation for fetus heart sound :

Discussion:


Remarks: