History Taking Flashcards
Information about the obstetric status of the patient
-Age
-Parity
-Gestation
-Previous pregnancy history
-Previous delivery history
-Booking BMI
Types of parity and gravidity
-PARITY= number of deliveries after 24 weeks of pregnancy
-GRAVIDITY= number of pregnancies you’ve ever had including current pregnancy
-NULLIPARITY= no pregnancies
-PRIMIGRAVIDA= in first pregnancy
-PRIMIPAROUS= given birth once after 24 weeks
-MULITGRAVIDA= pregnant more than once
-MULTIPAROUS= given birth more than once
=Plus means twins/ pregnancy ended before 24 weeks
Common obstetric presentations
-PV bleeding
=Gestation (before after 24 weeks), triggers, amount, appearance, associated symptoms (sore- antepartum haemorrhage causes)
-Abdo pain
=Location, labour?
-Hyperemesis
=How often vomiting, keeping anything down, scans, twins that run in family? reflux, diarrhoea, hot and shivery, foreign travels
-SOB/chest pain
=SOCRATES, swollen legs
-Hypertension
=new? blood pressure problems in previous pregnancies, pre-eclampsia symptoms (swollen legs)
-Headache
=Sudden onset? Changes in posture/ epidural/ changes in vision/ temperature/ location
-Reduced FMs (patterns)
Generic gynae information
-Age
-Parity (when, types of delivery, weights)
-LMP (first day)
-Cycle (regular? How much blood?)
-Smears (up to date, any abnormal, any treatment)
-Contraception (plans for future fertility)
-HRT (type)
-Previous surgery
-Smoker
-Fluid intake (alcohol, caffeine, fizzy)
-Elicit drugs
-Effect of symptoms on QOL
Common gynae presentations
-Heavy/painful menstrual bleeding (sanitary towel/ tampons, change, dysmenorrhoea, skin changes, hirsutism, anaemia, pain during sex, pain when in relation to period, clotting)
-Irregular periods (weight, PCO symptoms, pregnancy test)
-Postmenopausal bleeding (heaviness, pain, still happening/stopped, HRT, tamoxifen, FHx)
-Pelvic pain (during sex?)
-Pain during sex (very time or position)
-Incontinence issues (urgency, caffeine, alcohol, juice, leakage. when they cough? Nocturia and dysuria)
-Lumps and bumps (when did you notice, itchy, sore, bleeding, affecting sitting down, is it growing)
Urinary specific history
-Stress
=Leaking coughing/laughing/ running
-Urge
=Needing to get to toilet asap (Wet or dry/ Provoking factors)
-Frequency; number of times PU
-Nocturia
-Haematuria/dysuria
-Feeling incomplete bladder emptying
Prolapse specific history
-Bulge
=Dragging/discomfort/ heaviness
=‘lump coming down’
=Discomfort/ backache
=Ulceration
=Bleeding/discharge (secondary to ulceration)
-Bowels
=Constipation
=Incontinence
-Sex
Differentials for RIF pain
-Ectopic
-Ovarian torsion
-Cyst accident
-Mittlelschmerz
-TOA/ PID
-Cancer
-Renal stone
-UTI / pyelo
-Gastroenteritis
-Appendicitis
-Mesenteric lymphadenitis
-Constipation
-MSK pain
-Trauma
-Back pain
-Shingles
Systemic review
-Diet/ bowels/ bladder symptoms
-Infective symptoms
-Sick contacts/ travel
-Abnormal discharge/ bleeding
-Ask specifically about symptoms to help with relevant positive and negatives
Sexual history
-Sexually active
-Previous STI screening
-Previous STI infections
Menstrual history
-LMP
-Cycle length
-Any issues e.g. dysmenorrhea /menorrhagia
-Age of menarche
Key questions in obstetrics
-Gestation
-More details obstetrics history including previous pregnancies
=Antenatal / intrapartum / post partum complications
=Mode of delivery
-Bleeding (Rh status / placental location / cervical smear hx)
-ROM (water broke?)
-Fetal movements
-Pain
Bleeding history
-Weight loss / night sweats / fatigue
-Ovarian cancer: bloating / changes to bowels
-Detailed menstrual history (not as important in obstetrics)
-Detailed contraception / hormonal methods used
-Are they pre or post menopausal**
-Past history chlamydia?
