HISTORY TAKING IN OBGYN-1ihhygghhbbb.pptx

Nill

1. HISTORY TAKING IN OBSTETRICS & GYNAECOLOGY DR DAVID BREWEN CONTEH MS MCH

2. LEARNING OBJECTIVES By the end of this lecture students should be able to; Take a detailed obstetrics and gynecological history

3. PRINCIPLES OF HISTORY TAKING Respect, confidentiality and privacy are very important Information should be logical and also in chronological sequence History should guide a clinician to make a provisional diagnosis and perform proper and relevant investigations

4. INTRODUCTION OF THE PATIENT Name , Age, Marital status, Occupation Gravidity : N umber of pregnancies including this pregnancy Parity : N umber of pregnancies/deliveries reaching fetal viability Abortion : Termination of pregnancy before fetal viability, It is represented by a plus (+)

5. Example: Para 5 + 0 means: had 5 deliveries without abortion Para 4 + 1 means: 1 abortion (loss of previable fetus <28wks)

6. GESTATIONAL AGE LNMP : Last Normal Menstrual Period Is the 1 st day of her last normal menstrual period EDD : Expected/Estimated Date of Delivery Pregnancy duration is 280 days or 40 weeks

7. This can be calculated by Naegele’s rule Add 7 to the LNMP date and add 9 to the LNMP month if the month is below March OR Subtract 3 if the month is above March

8. EG: I f LNMP was on 15 th July 2009; EDD will be 22 nd April 2010 If LNMP was on 9 th Feb. 2009; EDD will be 16 th Nov 2009 NB: Assumptions made by Naegele’s rule are; Regular cycle of 28 days Woman not on contraceptives

9. GESTATIONAL AGE: Is calculated by counting the number of days from the LNMP dates up to today’s date. The you divide the number of days by 7 to get weeks of gestation

10. Gestational Age: Dates can also be calculated from ultrasound before 20 weeks by; The crown-rump length is used up until 13 weeks and 6 days Head circumference from 14 to 20 weeks After 20 weeks, variability of growth makes it unsuitable

11. CHIEF COMPLAINTS: Simple, clear with duration of symptoms Arrange them in order of occurrence/ chronological order Eg - Amenorrhea/ 4 months - vaginal bleeding/ 2 weeks - abdominal pain/ 3 days

12. HISTORY OF PRESENTING ILLNESS [HPI]: Amplify the complaints/symptomatology: onset, character, site, associated factors or precipitating/ aggravating factors Possible causes and risk factors Likely Complications Health seeking behaviour

13. SYSTEMIC REVIEW REVIEW OF OTHER SYSTEMS To know how does the disease affect the other systems Review systems which were not included in the HPI CNS RS CVS GIS GUS MSS

14. HISTORY OF INDEX PREGNANCY: Preventive services; IPT, Hematenics , PMTCT, GA at booking, number of visits Weight gain BP on each visit Hb level, VDRL, Blood group & Rhesus factor HIV status (ARTs if positive) IPT, Hematinic and Deworming Ultrasonography Vaccination e.g. TT

15. PAST OBSTETRIC HISTORY Outcome of each pregnancy: When, GA, Weight, Sex, Alive or Dead now. Previous pregnancies complications : Intra uterine fetal death. Preterm delivery Pre eclampsia Abruptio Congenital abnormalities Macrosomic baby Unexplained stillbirth Mode of delivery of previous pregnancies and their complications: Cesarean section Difficult vaginal delivery Post partum hemorrhage Significant perineal trauma Breast feeding

16. GYNECOLOGICAL HISTORY Age at menarche Pattern of bleeding: regular or irregular L ength of a cycle and duration of menstrual flow Amount of blood loss: scanty/heavy or normal and any passage of clots Number of sanitary pad used

17. Previous infections e.g. STIs and their treatments Previous gynecological surgery (e.g. myomectomy, cystectomy, D & C etc ) and complications Previous history of subfertility and IVF When was the last cervical smear? Was it normal?

18. SEXUAL AND CONTRACEPTIVE HISTORY Age at first sexual contact Frequency of coitus Number of sexual partners Sexual dysfunction, dyspareunia etc Contraception currently and previously used, and any problems with it

19. PAST MEDICAL AND SURGICAL HISTORY Number and reasons for admissions Relevant medical problems; Diabetes mellitus Hypertension Bronchial asthma Renal disease Epilepsy Any previous surgical operations, dates and complications Any history of blood transfusion

20. FAMILY AND SOCIAL HISTORY Marital status Occupation and partner’s occupation Number of family members/ family size H ereditary diseases in the family e.g. Hypertension, DM, Asthma, pre eclampsia, Hemoglobinepathies etc.

21. Family history of multiple gestation Family history of gynecological cancer (ovarian, endometrial, colorectal) or any other cancer e.g. breast cancer Smoking, alcohol or drug abuse

22. SUMMARY The history should be summarized in one or two sentences It includes; Age GPL and GA The important + ves leading to the Dx Example: Mrs. X 34 years old teacher G5P3+1L2 GA 37 weeks with previous CS known hypertensive admitted for control of BP.

23. REFERENCES Obstetrics by ten teachers 19 edition Gynecology by ten teachers 19 edition http//www.uptodate.com