HISTORY TAKING Flashcards
bleeding in early preg ( b4 22 weeks)
1.miscarriage- pieces of conceptions, suprapubic spasmodic pain
2.ectopic pregnancy-spotting,dull aching to general abd pain,hypertension symptoms
3.molar pregnancy- pieces of moles,hyperemesis gravidarum
4.local causes- hypovolemia signs,anaemia
-sudden/insidious
-how long?
-amount?
-continuous/intermittent
-pain?
- progressive/decreasing
-fresh?
-current status
bleeding in late preg (aft 22 w)
1.placenta previa-patient knows
2.abruptio placenta-sudden pain,clots,no fetal movement
3.vasa previa (rare)
4.local cause- hypovolemia,fibroid,polyps
abdominal pain early preg
1.miscarriage
2.ectopic pregnancy
3.UTI
4.surgical cause (appendix)
gynae:PID,twisted ovary
-intensity
-location
-character
-sudden/insidious
-how long?
-continuous/intermittent
- progressive/decreasing
-asso symp:UTI,GIT
abd pain late preg
1.Labor
2.Abruptio placenta
3.Ruptured uterus
4.UTI
5.Red degeneration of fibroid
-intensity
-location
-character
-sudden/insidious
-how long?
-continuous/intermittent
- progressive/decreasing
-asso symp:UTI,GIT
CLOTS
HYPOVOLEMIA
SEPTICAEMIA
GDM
History to be asked:
-TYPE
-WHEN N HOW DIAGNOSE,-MGTT N BSP VALUES
-treatment taken + DOSE
-How often was blood sugar profile checked + When was the last time checked?
-Symptoms of hypoglycaemia (weakness,giddiness,sweating,palpitation)
-Symptoms of diabetic ketoacidosis ~ ICU admission
~ Breathing difficulties
~ Fast deep breathing
~ Fruity odour breath
- Symptoms of uncontrolled DM
~ Polydipsia
~ Polyphagia
~ Polyuria
~ Infections :UTI, vulvovaginitis in current pregnancy
-family h/o of DM
-Detailed dietary history
~ Type (Carbohydrate rich, Protein rich)
~ Vegetarian/Non-vegetarian
~ Number of meals per day
-previous GDM- macrosomia, polyhydramnios, shoulder dystocia in previous pregnancy
-Detailed dietary history
Gestational Hypertension/pregnancy induced hypertension (PIH)
- Pre-existing & early diagnosed
- Type of hypertension
- Medication (dose,route)
- Controlled/uncontrolled
- Signs and symptoms
- Headache
- Blurring of vision
- Dizziness
- Vomiting/nausea
- Epigastic pain
- Reduced fetal movement
- Decreased urine output
consequence n complication of PIH
Consequences of PIH - Renal failure
- Cardiac failure
- CNS symptoms
- Transient ischemic attack
Complication :
- maternal : pre-eclampsia, eclampsia, renal failure, abruptio placenta, cardiac failure, liver failure, DIC
- Fetal : IUGR & IUFD
PROM/leaking pv
History to be asked:
1.duration
2.continuous/intermittent 3.colour(clear,green,red)
4.fever,chills,rigor
5.fetal movements
6.pain abdomen
7.foul smelling
prev LSCS (lower segment caesarean section)
- Type : lower or upper
- Elective or emergency
- Indication,week?
- Intra- operative complication
- Post op complications (wound discharge, fever, long hospitalisation)
- Gap between previous and current C-section
Anaemia- nutritional:supplements,diet
HAEMOLYTIC:med,thalasamia or sickle cell,
blood loss:acid peptic disease, prev menorrhagia,haemorrhoids
o Symptoms
~ Weakness
~ Giddiness
~ Syncopal attack ~ Breathlessness ~ Back pain
o Dietary history
~ Iron rich diet or supplementation taken? (Correct dose, timing
and route)
o H/o haemoglobinopathies
o H/o blood loss
~ Menorrhagia
~ Hookworm infestations ~ Epistaxis
~ Colonic polyps
o Symptoms of malignancy (leukemia) ~ Fever
~ Loss of weight
~ Anaemia
o Consequential symptoms
~ IUGR
~ UTI
Post natal
History :
o Mode of delivery
o Delivered at which week of gestation
o Any intrapartum, antenatal complications
o Baby details and its current status
o Excessive bleeding, foul smelling discharge, burning micturition,
pain abdomen, swelling of leg, shortness of breath, chest pain, sleep
patterns, mood, breastfeeding
preeclampsia
History taking
1. Pre-existing & early diagnosed 2. Type of hypertension
3. Medication (dose,route)
4. Controlled/uncontrolled
5. Signs and symptoms - Headache
- Blurring of vision
- Dizziness
- Vomiting/nausea
- Epigastic pain
- Reduced fetal movement - Decreased urine output
Stillborn
- fresh or macerated
- at what week of gestation
- underlying cause
- any obvious anomalies
- any post-mortem
- weight of baby
- any history suggestive of PE, GDM, IUGR
Reduced Fetal Movements
Why is it important? May progress to stillbirth.
Important History
- Since when?
- Progression eg: Normally, baby completes 10 kicks from 9 am to 3 pm. But since 1 day ago, since 9 am to 6 pm there were only 3 kicks.
- Etiological history: history suggestive of PE, GDM, IUGR, PROM
