Download MBBS (Bachelor of Medicine and Bachelor of Surgery) 4th Year (Final Year) History Taking in Obstetric Notes Handwritten Notes
EXAMINATION
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
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
CHIEF COMPLAINTS
? Period of amenorrhea with complaints of ?
? Apparently asymptomatic ? asked to get
admitted on account of
? No history of / negative history
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
? 2nd trimester ? anc visits , treatment taken, T.T. ,
quickening,etc
? 3rd trimester ?
? Comment about investigations done & treatment taken
Obstetric History
? G ? Gravida
? P ? Parity
? formula G P T- P-A ?L
? Describe each pregnancy - antepartum,
intrapartum, postpartum with its outcome with
emphasis on any complications
? Contraceptive history
Menstrual History
? Age of menarche
? LMP ? EDD by Naegele's formula
? Regularity , duration of cycle,
? Past history
? Personal history
? Family history
? Dietary history
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
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
Inspection
? Abdomen is distended with gravid uterus ?
longitudinal, transverse, oblique
? Umbilicus ? normal/inverted/everted
? Skin- stria, linia nigra, scar marks, visible veins
? Hernial sites
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
Auscultation
? FHS ?Location, rate
? Cephalic ? spino-umblical line
? Breech ? around umbilicus
? In occipito-posterior-in flanks
? Transverse lie- above umbilicus
This post was last modified on 11 August 2021