OBSTETRICS - history taking
- IDENTIFICATION DATA
- Name -
- Age -
- Residency -
- Education -
- Profession -
- Husband's Name -
- Husband's profession -
- time since marriage →
- Husband's Blood group →
- [Booked/Unbooked]
- [Registered/Referred]
- Blood group →
- LMP→
- EDD→
- G P [T.P.A.L]
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- Chief COMPLAINTS (great detail)
- PRESENT PREGNANCY
- 1st trimester
- Nausea-Vomiting
- Folic Acid tablets (Yellow)
- Ultrasound (& date?)
- Tetanus toxoid
- Fever
- Pain-Abd./pelvic/back
- Burning micturition
- Discharge
- Bleeding p/v
- ANC visit?
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- period amenorrhea →
- Conceivement → spontaneous/planned/treatment
- Realization of pregnancy → symptoms/tests with other
- confirmation of pregnancy→
- 2nd trimester
- Iron+ Folic Acid tablets
- Quickening - date?
- Ultrasound
- Tetanus toxoid?
- Fever
- Pain-Abd/pelvic/back
- bleeding-plu
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- 3rd Trimester
- Ultrasound
- ANC visits?
- bleeding plu
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- 1st trimester
- Post-NATAL
- breastfeeding
- Lochia ~ Odor, colour
- urinat of mother
- feces of mother
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- PAST OBSTETRICS HISTORY → * for each pregnancy *
- Pregnancy
- outcome of pregnancy
- gestational age at delivery
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- Delivery
- Normal/ C-Section (Why?)
- LABOR-induced/spontaneous normal/prolonged
- Perperium
- complications
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- Baby & Gender
- # Age (current)
- #Birth wt:
- # breastfeeding
- #immunization
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- if Abortion (method of) # place of delivery→
- #complications →
- Pregnancy
- MENSTRUAL HISTORY
- Monarch - Age
- Cycle - No. of days
- Rhythm - Regular/ Irregular
- Post-coital bleeding
- Contraceptive use
- Note LNMP here if not noted before
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- PAST HISTORY
- H/o blood transfusion
- any surgery
- Chronic disease -
- DM
- HTN
- TB
- (Pelvic inflammatory) Disease
- other (medicine History)
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- Family History
- Personal History
- diet
- Smoking
- alcoholism
- Allergy
- (Drug allergy)
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This download link is referred from the post: MBBS 2021 Important Topics and Materials for 1st Year, 2nd Year, 3rd Year and Final Year