O&G: Obstetric History structure

Question 1

Obstetric history: Structure (10)

Answer 1

Intro

Presenting Complaint

Current Pregnancy

Past Obstetric History

Past Gynaecological history

Past Medical History

Drug History

Family History

Social History

Wrapping up

(I Purchased a Cheap, Old, Grey, Manky Sofa from DFS, Oof)

Question 2

Intro (2)

Answer 2

• Can I just confirm your name and date of birth?
• And that makes you how old?

Question 3

Presenting Complaint (12)

Answer 3

• Why have you come in to the hospital today?
• //SOCRATES sieve for pain, but for any presenting complaint, use OATES*
• Where is it affecting you?
• When did this come about?
• Was it sudden or gradual?
• How would you describe it?
• Does the pain radiate anywhere?
• Have you found anything to be associated with this?
• Is it worse at a particular time of day?
• Episodic or constant?
• Have you found anything makes it worse or better?
• How severe is it?
• How is it impacting your daily life?

Question 4

Current Pregnancy (28)

Answer 4

• (T) How is the pregnancy going?
• //General History questions*
• How many weeks?
• Do you have an expected due date?
• What was the date of your last menstrual period?
• Was the conception natural or IVF?
• Any abnormalities detected on the scans?
• How has baby’s growth been?
• Have you noticed a decrease in the size of your tummy?
• Have the baby’s movements been ok?
• Have you had any unexpected complications along your pregnancy so far?
• Do you have any plans for delivery as of yet?
• //Pre-eclampsia*

-Have you had any headaches?

-Any abdominal pain?

-Any visual disturbances?

-Any nausea and vomiting?

• //Gestational diabetes*
• Any change in how often you pass urine?

-Any increase in thirst?

• Any fatigue?
• //VTE*
• Have you noticed a change in the colour of your skin?

-Any Shortness of breath?

-Have you noticed you’ve been breathing more quickly?

-Any swelling in one of your legs?

-Pain in your legs?

• //Antepartum haemorrhage*
• Have you had any vaginal bleeding?
• Have you had any hypertension?
• //HIV and other*
• Have you had any infections?
• Do you know about your rhesus blood type? (Positive or negative)
• How has your mood been?

Question 5

Past obstetric History (15)

Answer 5

• (T) Have you had any previous pregnancies?
• How many children do you have?
• How old are they?
• Do you remember how heavy they were when they were born?
• Did you experience any complications at any point with your previous pregnancies?
• Were they normal deliveries or C-sections?
• Any assistance with tools?
• Were the pregnancies delivered at full term?
• Did you experience any health problems after giving birth?
• Any congenital birth defects?
• Have you had any miscarriages in the past?
• At how many weeks gestation did this occur?
• Have you had any terminations of pregnancies?
• What were your reasons for termination?
• So in total, you’ve had how many pregnancies?

Question 6

Past Gyanaecological history (8)

Answer 6

• (T) I would like to ask about more general past medical problems, if that’s ok?
• Have you had any gynaecological problems in the past?
• When was your last smear test?
• Did you use contraception before getting pregnant?
• Did you have difficulties in getting pregnant?
• Did you have a sexual health screen before getting pregnant?
• Have your pregnancies been with the same partner?
• Have you had any sexually transmitted infections in the past?

Question 7

Past Medical History (6)

Answer 7

• (T) Have there been any other reasons you’ve had to see a doctor in the past?
• Any surgical procedures?
• Any reason to see a psychiatrist?
• Any previous diabetes?
• Any previous autoimmune disease?
• //Systems review (CRANK)

Question 8

Drug History (3)

Answer 8

• Is there anything you take medications for?
• Do you have any Allergies?
• Namely penicillin or latex?

Question 9

Family History (5)

Answer 9

• Are there any health conditions that run in your family?
• Has your mother ever told you about complications with her pregnancies?
• Any conditions where the blood clots more easily
• Any diabetes in the family?
• Mental illness in the family?

Question 10

Social History (9)

Answer 10

• (T+) Now I would like to ask you a few background questions about yourself, is that ok?
• We ask these to everyone.
• Who do you live with at home?
• Everything ok at home?
• Do you feel safe at home?
• What do you do for a job?
• Do you smoke?
• Do you drink?
• Do you do any recreational drugs?

Question 11

Wrapping up (4)

Answer 11

• Do you have any questions for me?
• Any concerns?
• Ok, that’s all I need to know for now. I will now discuss your case with my team.
• Thank you!