HISTORY TAKING & EXAMINATION
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KEYPOINTS
- It should be in paragraph like a story
- Complaints should be in chronological order
- It should be in patient's words
- It should guide clinician
- to form a provisional diagnosis
- to plan examination
- to plan investigations
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IDENTIFICATION DATA
- Name Age Residence Occupation Education
- Religion sex married
- Booked/unbooked/ registered/referred ?
- Time date & place of admission
- With chief complaints of
- Can give obstetric history- optional
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CHIEF COMPLAINTS
- Period of amenorrhea with complaints of –
- Apparently asymptomatic – asked to get admitted on account of
- No history of / negative history
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H/O Present Pregnancy
- How she conceived – spontaneous/ took treatment
- Diagnosed pregnancy
- First trimester – first visit to health center
- h/o fever, emesis, exposure to teratogen
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- 2nd trimester - anc visits, treatment taken, T.T., quickening,etc
- 3rd trimester –
- Comment about investigations done & treatment taken
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Obstetric History
- G - Gravida
- P – Parity
- formula GPT-P-A-L
- Describe each pregnancy - antepartum, intrapartum, postpartum with its outcome with emphasis on any complications
- Contraceptive history
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Menstrual History
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- Age of menarche
- LMP – EDD by Naegele's formula
- Regularity, duration of cycle,
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- Past history
- Personal history
- Family history
- Dietary history
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GPE
- Patient is lying comfortable, well oriented
- Built & nourishment
- Height, weight, BMI
- Vitals – PR, BP, RR, Temp
- GPE – PROPER
- Systemic – cardio- respiratory system
- Breast examination
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P/A Examination
- Pre- requisites – stand on right
- ask her to empty bladder
- thighs semiflexed with abdomen exposed ideally up to mid thigh
- Inspection
- Palpation
- Percussion
- Auscultation
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Inspection
- Abdomen is distended with gravid uterus longitudinal, transverse, oblique
- Umbilicus – normal/inverted/everted
- Skin- stria, linia nigra, scar marks, visible veins
- Hernial sites
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Palpation
- Correct dextrorotation
- Fundal height – by ulnar border of hand
- Measure SFH and abdominal girth
- 4 grips - fundal grip
- lateral grip
- first pelvic grip
- second pelvic grip
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Auscultation
- FHS -Location, rate
- Cephalic - spino-umblical line
- Breech - around umbilicus
- In occipito-posterior-in flanks
- Transverse lie- above umbilicuS
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This download link is referred from the post: MBBS Lecture Notes for all subjects (updated for 2021 syllabus) - All universities
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