Obstetric "To ask" checklist / History Taking.
We often feel clueless or unsure what to ask when we are in the obstetric department.
This post is an example of the template I had in my notes while I am in med school, just want to share with everyone.
There are 10 aspects we can ask from to understand them better.
All of them are for references only, use them wisely😀
Demographic
- Name, Age
- Occupation
- Ethnic
- Chief Complain
Current Pregnancy History
- Gestation , LMP/EDD
- Date from ultrasound
- Single/Multiple chorionicity
- Details from Chief Complain
- What action has been taken
- any other problems
- any bleeding, contraction or loss of fluid vaginally?
- Is there a plan for the rest of the pregnancy
Ultrasound History
- What scan? why?
- Any problems?
Past Obstetric History
- List of previous pregnancy
- G. P. A.
- Vaginal birth or C-section
- complication?
- baby weight
- Full Term? Pre-term.
- Baby's condition. eg. bluish, difficulty breathing,,,
Gynecology History
- Periods history
- when is the last period
- any abnormal or irregular menses.
- Contraceptive history
- Previous infection and treatment did
- When is the last cervical smear or screening. Is it normal ? and any treatment?
- Any history of surgery
Post medical and surgical
- Any medical related issues. eg. IDA, diabetes...
- any previous operations?
Psychiatry
- Postpartum Blues
- Depression
- Major illness, eg: schizo
Family History
- Diabetes
- Hypertension & etc. (chronic illness)
- Psychiatry
- Genetic
Social history
- Smoking/ alcohol/ drugs, etc...
- Marital status and their relationship
- Partner's occupation
- Financial status. eg: any helper at home? etc.
Drug History
- Any folate supplement used (for pregnant lady)
- Allergies to food/ medicine
- if yes, what are the symptoms.
SO that's all that you need to ask whe you approach a pregnant lady. Every lady has a different situation and problem, so you will also need to make a decision which question you would like to "double click" and understand more about the details that you need to make a primary diagnosis.
Hope this article helps, Good luck!
