Obs  Hx &  W U + Eg
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Guide on how to do a proper obstetric clerking with sample histories

Guide on how to do a proper obstetric clerking with sample histories

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Obs Hx & W U + Eg Presentation Transcript

  • 1. OBSTETRIC HISTORY & WRITE-UP By Associate Professor Dr Hanifullah Khan
  • 2. Importance of History Taking• Obtaining an accurate history • The critical first step in determining the aetiology of a patients problem.• A large percentage of the time, a diagnosis can be made based on the history alone.
  • 3. The obstetric history• 2 purposes – Provide a synopsis of background risk – An account of the progress of the pregnancy• A carefully taken history – provides a clinical guide for the P/E to follow• History should be taken & presented in a logical sequence
  • 4. Complete History Taking• Chief complaint• History of present illness• History of current pregnancy • Gyn/ob history.• Past medical /surgical history• Family history• Drug /blood transfusion history• Social history
  • 5. Order of histories• Mandatorily, the initial sequence must include – CC, HOPI, HOCP & HOPP – in that order, – although HOPI and HOCP may be combined if required. • Other histories such as – medical, surgical, family, social, drug and menstrual or gynae history then follow – but these may be rearranged – in order of relevance to the HOPI or HOCP.
  • 6. CHIEF COMPLAINT
  • 7. What is the “Chief Complaint”• This is the main reason the pt presented• Usually a single symptom, – occasionally more than one complaint eg: chest pain, palpitation, shortness of breath• The patient describes the problem in their own words It should be recorded as such• Short/specific in one clear sentence• Must have duration of problem – “per Vaginal bleeding for 3 days prior to admission”.
  • 8. Example of chief complaint My patient, Mrs Norizan a 29 years oldschool teacher who is 35 weeks into her G2 P1 pregnancy has been admitted to the ward yesterday due to leaking liquor three days prior to admission. should be changed to "leaking liquor 3 days prior to admission"
  • 9. Details & progression, regression of the CC:HISTORY OF PRESENT ILLNESS
  • 10. History of Present Illness - overview• Elaborate on the chief complaint in detail• Ask relevant associated symptoms• Have differential diagnoses in mind
  • 11. Components of HOCI1. Demographic info2. Primary history – 1. - Onset, course, severity, duration3. Associated symptoms4. Symptoms of any complications
  • 12. Important points• Always relay story in days before admission e.g. • “the patient was apparently well until 1 day prior to admission…”• If patient has > 1 symptom, • take each symptom individually and • follow it through fully • mentioning significant negatives as well• Avoid medical terminology
  • 13. Demographic information• Appropriate to begin with a summary of the details• Name, age , gravidity, parity, LMP, EDD (Naegele’s rule) Gravidity - no. of pregnancies including current pregnancy (regardless of the outcome) Parity - no. of births beyond 24 wk gestation
  • 14. Look at this demographic dataMadam Norizan Hussein a 29 years old Malay lady, gravida 2para 1, is now at 35 weeks maturity. Her last normal menstrual period was on 25/4/2011 and the expected I date is on 1/2/2012. This is just one way of writing the demography.
  • 15. Primary history• Describes the onset, – -Anatomic location course, severity and duration of the chief – -Quality complaint – -Quantity or severity – elaborates on the main – -Timing complaint – -Setting in which the – deals with the chronology & symptoms occur the characteristics of the – -Aggravating or relieving chief complaint. factors• Chronology & – -Associated symptoms characteristics of the current symptom:
  • 16. Primary Hx cont..• If > 1 chief complaint, repeat this series of questions for each complaint• Not all questions may be relevant for a symptom – For example, a location cannot be determined for “difficulty in breathing”.
  • 17. Associated symptoms• A general review of systems • Requires more experience on the part of the interviewer than before• Information gathered here serves to – support the diagnosis – as well as to gauge the severity of the disorder• Examples – abdominal pain - presence or absence of nausea and vomiting – vaginal bleeding - per vaginal discharge, pruritis or smell.
  • 18. Symptoms of complications• Again - help to confirm the diagnosis and assess the severity of the problem – thus establishing an idea of the management that is to follow• Examples – For complaint of symptoms of dysuria & increased frequency of micturition - loin to groin pain, backache & fever – might suggest ascending infection complicating the UTI
  • 19. From this History of Current Illness..My patient first experience leaking liquor on 23 /12/2011 when she was at her house. The leaking is sudden in onset. The leaking occurs in less than 12 hours and patient straight away come to the hospital afterthe first episode of leaking. Patient claimed leaking occurs once during morning estimated about one cup full and recur in spotting manner. Then the amount of the leaking decreases throughout the day. Theliquor is transparent in nature, no foul smelling and not associated with pain or bleeding. The patient said she had vaginal itchiness which resolved with medication three days before the episode of the leaking happen. Patient denied any increase in frequency of urination anddysuria. Bowel opening is normal as there is no altered bowel habit, no constipation and no diarrhoea.
  • 20. To this improvement.. My patient is was well before the episode of leaking liquor occurs. The leaking happened spontaneously without any significant aggravating andprecipitating factor. The duration of the leaking is less than 12 hours. Patientclaimed leaking occurs once during morning which soak half of her sarung and recur in spotting manner. Then the amount of the leaking decreasesthroughout the day. The liquor is transparent in nature, and no foul smelling detected. The episode of leaking liquor is not associated with pain or bleeding. Patient denied any fever before k. She claimed that she had vaginal itchiness which resolved with medication three days before the episode of the leaking. Patient denied any increase in frequency of urination and pain when passing urine. She also denied any history of trauma and accident. Although the grammar needs improvement
  • 21. And the whole HOCI will then resemble this.. Madam Norizan Hussein a 29 years old Malay lady with gravid 2 para 1 pregnancy is now at her 35 weeks period of maturity. Her last normal menstrual period was on 25/4/2011 and the expected delivery date is on 1/2/2012. My patient is was well before the episode of leaking liquor occurs. The leaking happened spontaneously without any significant aggravating and precipitating factor. The duration of the leaking is less than 12 hours.Patient claimed leaking occurs once during morning which soak half of her sarung and recur in spotting manner. Then the amount of the leaking decreases throughout the day. The liquor is transparent in nature, and no foul smelling detected. The episode of leaking liquor is not associated with pain or bleeding. Patient denied any fever before that. She claimed that she had vaginalitchiness which resolved with medication three days before the episode ofthe leaking. Patient denied any increase in frequency of urination and pain when passing urine. She also denied any history of trauma and accident.
  • 22. HISTORY OF CURRENTPREGNANCY
  • 23. Components of HOCP• Chronological & concise account – 1st, 2nd & 3rd trimesters• How was pregnancy confirmed?• First trimester symptoms• Results of routine tests• Ultrasound scans• Subsequent antenatal check-ups• MOGTT, H/T
  • 24. Confirmation of dates• The patients gestational age should be confirmed by using the following points: • LNMP – Sure of date – Regular menstrual cycle• UPT – Brand?(Clearview®àmost sensitive UPT), detect β-hCG• Early pregnancy symptoms?when? (vomiting started at 6-7 week)• Quickening – Primigravida: 22-23 weeeks – Multigravida: 16-18 weeks
  • 25. Investigations• Routine tests – just mention if normal• Of particular importance – Hb & early BP reading – ABO and Rhesus blood grouping• Early u/s scanning – Document the number of fetuses, the viability & gestational age• Subsequent ANC – just mention if normal – 2nd trimester u/s scanning - to assess for fetal anomalies – This should be specifically mentioned even if not done.
  • 26. DM• Nowadays, routine • Document if DM screening for DM screening was done, when – At first booking & the results – At 24-28 weeks of gestation • Must still list the risk if suspicion of DM arises or factors of DM persists • If results abnormal, ?• Previously, this was done subsequent action based on the presence of – regular serial sugar risk factors monitoring – Pts were being missed out – diet modification• 75g OGTT, HbA1c – oral or insulin therapy
  • 27. Fetal growth • Fetal growth is an important indicator of diabetic control and any development of macrosomia & polyhydramnios must be mentioned
  • 28. Prepregnancy disorders• Medical disorders in pregnancy - presence of the disorder prepregnancy – Must actively determine this – Important implications on the classification of the condition, the risks involved & the management of the pregnancy. • DM & HT - the most common medical disorders encountered – Epilepsy, thalassemia, anaemia and heart disease.
  • 29. This is a good example of HOCP.. Madam Chu had her last menses from 13th January 2011 to 16th January 2011.She was diagnosed pregnantby a private clinic on 25th February 2011(about 6 weeks period of amenorrhea), using a urine pregnancy test. On 9th March, she did her booking. At this visit, she was told that her blood pressure was 100/60mmHg, her weight was 90 kg and her urine test for albumin was negative, urine glucose was blue and her random blood sugar was 5.4 mmol/L. An ultrasound scan was performed and she was informed that it revealed an intrauterine gestation sac of about 8 weeks gestational, and a small fetal echo and its heart beat was visible. There was no abnormal mass noted on the uterus, the adnexal or within the pelvic cavity. The staff took her blood for some antenatal routine tests. During the next visit, she was told her blood was group A positive, her VDRL and HIV tests were not reactive. It is good as all the information is there, but you should write in a more concise form. Remember, the most information in the least words. The early pregnancy was associated with vomiting and nausea which did not require any medicaltreatment. During 19 weeks and 28 weeks period of amenorrhea she was diagnosed with urinary tract infection twice and treated with antibiotics and recovered well from both attacks of UTI without any complication.   She first felt the fetus movement on 17 weeks period of amenorrhea. Subsequently, she had her first dose of anti-tetanus toxoid vaccination one month later and completed with second dose of anti-tetanus toxoid vaccination on 14th  July 2011.   At amenorrhea of 19 weeks, Madam Chu was screened for Gestational Diabetes because she has a family history of diabetes mellitus and her body mass index (BMI) exceeded 30, which defined her as obese. Her MGTT was normal at 19 weeks. However, another repeat MGTT at 31 weeks showed impaired glucose tolerance with fasting blood sugar of 5.8 mmol/L and 2 hours post-prandial at 8.5 mmol/l. She was then managed as a case of gestational diabetes. She was referred to the dietician for dietary advice and subjected to blood sugar monitoring every two weeks.
  • 30. HISTORY OF PAST PREGNANCY
  • 31. Past Obs History• This section details the events & outcomes in the patient’s past pregnancies – May have important implications on current pregnancy – May also give clues on the current problem the patient is facing• Enough to summarize significant points rather than listing them out – Any significant antenatal, intrapartum or postpartum events – Any abortions & ectopic pregnancies &their outcomes have to be mentioned – Previous maternal complications
  • 32. Delivery & Baby• Mode of delivery• B Wt• Life & health of the baby• Contraception – – Type, when begun, why stopped, any side effects• Did the current complaint occur in past pregnancy?