A guide to obstetric clerkship for the student. This presentation deals with a patient who has come with a complaint.

1. A Guide To ObGyn Case
Presentation
OBSTETRIC
HISTORY I
For a patient who presents
with a complaint
Associate Professor Dr Hanifullah Khan

2. The importance of a good history
Introduction This section details the key
points of a clinical history

3. The Importance of Patient History
The critical first step in
determining the aetiology
of a patient's problem
A large percentage of the
time, a diagnosis can be made
based on the history alone
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

4. Proper Sequence History should be taken
& presented in a logical
sequence
Mandatorily, the initial
sequence must include !
• CC, HOPI, HOCP & HOPP in
that order, !
• although HOPI and HOCP may
be combined if required
• Chief complaint!
• History of present illness!
• History of current pregnancy!
• History of past pregnancy
• Gyn/ob history!
• Past medical /surgical history!
• Family history!
• Drug /blood transfusion history!
• Social history
The other components!
• then follow, but may be
rearranged in order of
relevance to the HOPI or
HOCP

5. This is an actual student history
Sample History

6. always begin with
chief complaint
there is only 1
patient history,
although it contains
many sections
do not use
titles for each
section,
instead use
paragraphs
the major
portion of the
history should be
the history of
current illness
The history
should be as
short as possible
- make
intelligent use of
descriptive
words & avoid
irrelevant &
unnecessary
words. Do not
repeat
information
!
This is an actual student
presentation!!

7. This is the main reason the patient has come to see you The Chief
Complaint
The patient describes the problem in
their own words
It should be recorded as such
Usually a single
symptom, !
occasionally more than one
complaint eg: chest pain,
palpitation, shortness of
breath
Must have duration
of problem!
Short/specific in one clear sentence

8. • Elaborate on the chief complaint in detail
• Ask relevant associated symptoms
• Have differential diagnoses in mind
History of Current
Illness
1.Demographic
info!
2.Primary history !
3.Associated
symptoms!
4.Symptoms of any
complications
Components of
HOCI
• Always relay story in duration (e.g. “the
patient was apparently well until 1 day
prior to admission”) and NOT time (e.g.
last Wednesday or in July)!
• If the patient has > 1 symptom, !
• take each symptom individually and !
• follow it through fully !
• mention significant negatives as well!
• Avoid medical terminology

9. Components of
HOCI!
1. Demographic
info!
2. Primary
history !
3. Associated
symptoms!
4. Symptoms of
any
complications
Demographic
Information
Appropriate to begin with a summary
Gravidity - no. of pregnancies!
including current pregnancy!
(regardless of the outcome)!
Parity - no. of births beyond !
24 wk gestation
of the details
Name, age , gravidity,
parity, LMP, EDD
*Actual student history - grammar, context and
other features can be improved!

10. Components of
HOCI!
1. Demographic
info!
2. Primary
history !
3. Associated
symptoms!
4. Symptoms of
any
complications
Primary
History
Describes the onset,
course, severity and
duration of the chief
Elaborates on the main complaint & deals
with the chronology & the characteristics
of the chief complaint
complaint
Some features of the 10 Hx!
• Anatomic location!
• Quality!
• Quantity or severity!
• Timing!
• Setting in which the symptoms
occur!
• Aggravating or relieving
factors
Note that not all questions may be relevant for a symptom,
e.g. a location cannot be determined for “difficulty in breathing”

11. Components of
HOCI!
1. Demographic
info!
2. Primary
history !
3. Associated
symptoms!
4. Symptoms of
any
complications
Associated
Symptoms
May serve as a general
review of systems
Information gathered
here serves to: !
• support the diagnosis !
• gauge the severity of the
disorder
Examples
❖ if a pt ℅ abdominal pain - must
ask for presence or absence of
nausea and vomiting!
❖ if a pt ℅ vaginal bleeding - per
vaginal discharge, pruritis or

12. Components of
HOCI!
1. Demographic
info!
2. Primary
history !
3. Associated
symptoms!
4. Symptoms of
any
complications
Symptoms of Complications
Again, this helps to confirm the diagnosis
& assess the severity of the problem
This will help in the
subsequent management
of the pt
Examples
For complaint of dysuria & increased
frequency of micturition - loin to
groin pain, backache & fever; might
suggest ascending infection
complicating the UTI

13. The Complete HOCI

14. Please do not forget this…
REMINDER!!
The most elaborate and largest component
of a patient history is the history of current
illness.!
!
All other components should be concise and
serve as supportive information for the
history of current illness.!

15. Antenatal history or…
History of Current
Pregnancy
In which you assess the status
of the current pregnancy and
its connections to the current
illness

16. The HOCP
Should be a chronological & concise account (1st, 2nd & 3rd trimesters)
Should have a !
few components
Confirmation of pregnancy
Antenatal booking & results of
tests
Results of ultrasound scans
Comorbidities

17. 1. Confirmation of pregnancy
This can be done in
a number of ways
❖ assessment of menstrual
period!
❖ urine pregnancy test (UPT)!
❖ assessment of symptoms!
❖ early ultrasound scan

18. Calculation from LM
The gestational date can be calculated
from the last menstrual period (LMP)
using Naegele’s rule
Assessment of
menstrual period
Accuracy is reliant on a few points:!
• must be measured using 1st day of LMP!
• periods must be regular of 28 day cycle!
• the pt must be sure of the LMP!
!
Calculation of dates is inaccurate if
any of these conditions are
unfulfilled

19. Urine test
Becomes positive around 5 weeks of
gestation
UPT
Subjective test - it doesn't
quantify gestation but may
suggest the duration of
pregnancy!
!
Not very specific nor sensitive -
false positives are common

20. The occurrence of pregnancy symptoms…
Assessment of
Symptoms
Quickening - the first sensation of fetal
movement :!
primigravida - felt between 22-23 weeks!
multigravida - felt between 16-18 weeks
may indicate the gestation & provide a
rough guide to the accuracy of the
menstrual dates
Common early pregnancy
symptoms are nausea, vomiting,
gastric symptoms & general
malaise:!
noticeable between 5-6 weeks
gestation!
usually quite accurate!
absence of symptoms is not
predictive of feral well-being
These symptoms become
important to confirm gestation
if an early ultrasound scan
was not done

21. Done within the first 12 weeks of gestation…
provides the most accurate assessment
of gestational dates. Every mother
should be encouraged to have one.
Early Ultrasound
Scan
Every early scan must answer at least 3
questions - the number of fetuses, their
health (viabilty) & the gestation!
!
A simple scan is used to measure the
Crown-Rump Length (CRL) for accurate
dating!
!
Always ask the patient if she has had one &
confirm the above 3 questions

22. 2. Antenatal booking & results of tests
Determine precisely!
❖ the booking Haemoglobin (Hb)
- the occurrence of physiological
anaemia in later trimesters
masks the actual blood content!
❖ the booking Blood Pressure (BP)
- this is to determine if the
patient has preexisting
hypertension (H/T)!
❖ if screening for diabetes mellitus
(DM) was done & the results
Early booking - important to determine
the initial well being of the mother as
well as for assessment of potential risks!
The 1st trimester is the time when the
patient is closest to the non-pregnant
state!
Subsequent hormonal & physiological
alterations tend to mask findings &
may confuse patient assessment
Other antenatal tests - Hepatitis
screen, VDRL, HIV - should just be
mentioned as normal & need not be
elaborated

23. 3. Results of ultrasound scans
❖ The early u/s scan is
considered the gold
standard for fetal dating!
❖ The 2nd trimester u/s
scan - assessment of feral
anomaly!
❖ 3rd trimester scan -
placental site, confirm lie
& liquor & size
It is important to ask the
pt about any scans done!
An early scan is one
done prior to 14 weeks
gestation
Ultrasound scanning is part & parcel
of modern obstetric practice. All
mothers should have access to this

24. 4. Comorbidities
The commonest are DM &
Hypertension (H/T)!
The incidence of preexisting disease
is increasing & it is common to find
mothers getting pregnant with
them
Other important comorbidities
include anaemia & thyroid disease
❖ Late pregnancy disease
usually affects growth &
well-being
❖ Differentiation between
early & late pregnancy
disease is crucial!
❖ Early pregnancy disease
has implications on fetal
development

25. This is a sample of the HOCP. It should not be too
long and contain all the necessary information.
Confirmation of
pregnancy
Investigations
during booking
Ultrasound scans
Screening for
comorbidities

26. Previous pregnancies and deliveries …
History of Past
Pregnancy (HOPP)
What happened in the past
may indicate the cause of the
current problem as well as
impact the current pregnancy

27. Summarize significant points
❖ Any significant ante-, intra-or
postpartum events!
❖ miscarriages & their
outcomes!
❖ Life & health of the baby!
❖ Contraception – Type,
when begun, why stopped,
any side effects!
❖ Did the current complaint
occur in past pregnancy?
Not necessary to
present everything!
An early scan is one
done prior to 14
weeks gestation
❖ Modes of delivery, baby
gender & birth weights need
not be presented individually

28. Additionally, breast feeding
(BF) should be asked for, &
reinforced as a positive attitude
This student has combined the
gynae/menstrual history with HOPP,
perfectly acceptable & useful
BF is also significant, as many
women have amenorrhoea or
abnormal periods due to
hyperprolacinaemia which may
impact the accuracy of dates

29. All the other stuff
Other components These components provide
supportive evidence for the
possible diagnosis

30. Remember this? History should be taken
& presented in a logical
sequence
Mandatorily, the initial
sequence must include !
• CC, HOPI, HOCP & HOPP in
that order, !
• although HOPI and HOCP may
be combined if required
• Chief complaint!
• History of present illness!
• History of current pregnancy!
• History of past pregnancy
• Gyn/ob history!
• Past medical /surgical history!
• Family history!
• Drug /blood transfusion history!
• Social history
The other components!
• then follow, but may be
rearranged in order of
relevance to the HOPI or
HOCP

31. The last part of the history
Rearranged according
to relevance
These histories support the
HOCI!
!
They should be brief!
!
Questions asked the patient
should be relevant to the
current problem or associated
with the management
• Gyn/ob history!
• Past medical /surgical history!
• Family history!
• Drug /blood transfusion history!
• Social history
The rest of the component
histories are arranged
according to their relevance
to the patient’s problem

32. An example
Most people consume alcohol
but are not dependant on it; it
is wrong to use the term
alcoholic ulnless there is
evidence of substance abuse
This is an abbreviated example of the other histories with relevance to
the patients problem!
!
Some questions such as family history of diabetes and hypertension are
universal - they are relevant irrespective of the complaint due to the
global impact of the disease!
!
Socioeconomic history serves to elaborate the status of the patient with
particular relevance to communicable disease!

33. This is the HOCI!
This should be the
largest component
of the history
This is the HOCP
& HOPP!
This should
follow the HOCI
The other
histories!
Make up the
smallest portion
of the full history
Any component history that is contributory to the diagnosis and significant,
should be made part of the HOCI

34. Happy Clerking!