History taking: Obstetric and gynaecology - Dr Obrein Flashcards
Overview: Lecture
Name, age, how many weeks gestation, current issuse, previous issuses, medical/surgical/psychosocial hx-
At the top- Put Gs and Ps- Obs gynae hx, morphology scnas/ix results - + other history
When do you need to review patients history and investigations? + documentation?
+ important facts- Needs to know blood groups
+ HIV/HC/LFTS EGFR
+ BSL/HBa1c +TFTS
At 28 weeks antenatal - want to see how they are tevelling + ask qs specific to preclampsia +assk about mum and baby (movements), pain, discharge, ask always if baby is moving!!!!!! always ask!
basics:
outline
General history points: Routine questions
- have you had any sugar problems? any BP problems?
- Any headaches wont go away with paracetomol? Pain? Bubs moving? Nand Vomitting
- Always listen to all concerns
Have a template to remember:
Dmeographic info- Do you have a supportive partner?
Previous pregnancy?
- how many? Gravida parity?
- how long?
- alive?
- how was birth? method of delivery?instrumental vs c vs vaginal- tears? bleeds? theartre? Tears in your bottom?
- Previous weight? complications? issues around delivery?
- terminations? TOP?
Previous pregnancy continued?
Year?hosp? Gestation? Mode? Complications? Neonatal?
Current pregnancy- (Dating) Questions to ask? spontaenous vs ivf? date LMP? Cycle length? abnormal bleeding? pain? ocp?
Current pregnancy- dating more information:
Estimated date of delivery: read- Measurement
What is the CRL? Crown rump length?
How high does your hormones have to be to support pregnancy?
>1500 bet hcg should be able to see intrauterine pregnancy
Why does EDD matter?
because management at different stages- E.g labor/bleeding/n&v
Current pregnancy? History questions on review?
Pattern of movement? have they changed? do they have a change to pattern of movements? most will not feel movements until about 20 weeks! (key point to know)
- Movement and pattenr of movement important after 24 weeks
- if someones placenta is at the front the mum may not feel movement quite as early
Gynae history: List key points:
- bladder and bowels?
- Surgery on tummy? hx of infertility
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Previous medical hx (key conditons to ask for on medical hx) and ask about management:
Surgical/anaesthetic history-
- any previous anaesthetics? Any issues?
- back problems? surgery-epidural
- previous blood transfusion? - worrying about rhesus d- and abnormal antibodies- (can contirbute to hameolytic anasmeia)
Drug and alcohol history?
- stop smoking! - cut back, think abou quitline
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How to document:
How to present patient:
What are the 3 levels of delancey- surgical planes for
