History Clerking

VSMU OBGYN workshop 2012

History clerking, physical examination of Obstetrics patients.

Etiquette:

Always introduce yourself,tell the patient who you are and say why you have come

to see them.

Sensitive to intensely private data.

Some women will wish another person (chaperon ) to be present if the doctor or students is

male (even female), even just to take a history and this wish should be respected

IDENTIFICATION DATA :

Name: R/N: Ward :

Ethnicity: marital status: SMS/2nd

union

Age: * <18y.o, *>35y.o

Date of birth:

Date of admission:

Date of delivery/operation:

Date of discharge:

Date of clerking:

Gravida/ para: (twins/abortion/molar pregnancy)

Gravidity : no. of pregnancies of any gestation regardless of how they ended;,

including present one

Parity = Number of live births at any gestation and stillbirths delivered after stage

of viability (24wks) (either by vaginal or operative routes)

E.g.:

1) Lady on her 1st pregnancy – G1P0

2) Woman had twins and pregnant now (24wks) – G2P2

3) A woman has had 4 miscarriages and is pregnant again with only one live baby; she is at 26

wks of gestation now – G6P1+4

4) A lady in her 6th pregnancy, with history of 1 abortion and 1 molar pregnancy – G6P3+1

abortion,1 molar pregnancy.


Last normal menstrual period(LNMP):

Sure of date SOD

Unsure of date USOD (calculated from REDD- )

REDD : ( if USOD, do early scan @ ~ 10weeks,if >1 weeks discrepancy,

REDD should be given .)

Period of amenorrhea (POA)/ gestation (POG) :

POA by LMP; POG by U/S (if REDD is given earlier,use it to calculate POG)

Expected date of delivery(EDD): ( if pregnant) by LMP or by scanning

EDD

Naegele’s rule :

Add 7 days to LMP, subtract 3 months from the month OR

Add 7 days from LMP and add 9 months to the month.

Criteria:

1. Regular MC

2. Not on OCP within 3 months

3. Not on breastfed prior to amenorrhea

4. Pregnancy not via ACT (IUI/IUD/IVF)

calculate POA from LMP:

steps:

1.find LMP

2.minus date of clerking

3.change the months & day into week and then plus additional day & week.

& follow this rules : or simply deduct the number of weeks from the EDD.

3 months = 13 weeks

2 months = 8 weeks 5 days

1 months =4 weeks 2 days. 1. 4 weeks + 2 days

2. 8 weeks + 5d

3. 13 weeks

4. 17 weeks + 2 d

5. 21 weeks +5d

6. 26 weeks

7. 30 weeks+ 2d

8. 34 weeks+ 5d

9. 39 weeks


* Gregorian calendar says one month has 30-31 days (except Feb) or if in weeks, about 4.33 weeks.

1week = 7 days—1day ~ 0.14 week; 1mth = 31days= 4 weeks 3 days= 4 weeks + (3x 0.14 weeks )= 4.42 weeks 1 mth= 30 days = 4 weeks 2 days = 4 weeks + (2x 0.14)= 4.28 Average = (4.28+4.42) /2= 4.35 * maknanya we have about 0.42 week ( 3 days) missing each month. We have to correct this loss. Actually this 0.42 week loss akan menjadi 1 week lepas tiga kali round, or three months (0.42+0.28+0.42 = 1.12 week). (approximate 1 week) Sebab tu every 3 months, kita correctkan defect tu dengan add 1 week tadi. Meaning: 4 week + 4 week +4 week +1 week = 3 months

CHECK LIST FOR OBSTETRIC CASE

1. chief complaints

2. History of Present Illness

3. History of present pregnancy/antenatal history

4. Past Obstetric History

5. Gynaecological History

6. Contraception History

7. Past Surgical History

8. Past Medical History

9. Drug history

10. Family History

11. Social History

2.CHIEF COMPLAINTS(c/o):

a) reason admitted

b) test done

eg. Diagnosed to have gestational diabetes at 30 weeks.

*problem must be listed in priority if there are multiple problems and explained concisely and

adequately Eg. Admitted upon her booking visit for high blood pressure of 150/93 mmHg compared to

previous baseline blood pressures of approximately 120/80 mmHg.

Eg. Madam Ling is a 25 y.o Gravida 3 para 2 chinese,at 32 weeks POA who is admitted for

painless PV bleeding for 1 day duration for further management.

Her LMP was on 15th

September 2011.she has regular 28-30 days menstrual cycle. Therefore her

EDD is on 22nd

of june 2012 by LMP.


3.history of presenting illness

4.history of presenting pregnancy (HOPP) Marital status : when,age,how many marriages

This is her ___ pregnancy with POA ____

1. Unexpected but wanted or ―unwanted‖? or planned?

2. Why suspect pregnancy?

3. When?where?who?how to confirm pregnancy?

Urine pregnancy test (UPT)? Ultrasound?

Patient got married in 1992. According to the patient, this is a “long awaited”/planned pregnancy after

being unable to conceive for 17 years. Her suspicion of a pregnancy was raised when she started having

symptoms of pregnancy such as nausea and morning vomiting episodes. She had a urine pregnancy test

at POA 17 weeks at Klinik Kesihatan Marang and was tested positive.

Early pregnancy(check antenatal book- pink book)

Booking date - ___ ( @ POA) , @KKIA ___

Booking BP –

Height – Weight—

Blood group & rhesus--

Haemoglobin--

Urine glucose--

Urine protein--

VDRL-- HIV ---

(fundal height)—

Immunization (when? How many doses?)

Antitetanus toxoid

Hepatitis B

rubella

Others : MOGT done? (indication : FHx,age > 35,excessive weight gain,

previous macrosomia,GDM,fetal abnormalities)

Subsequent antenatal check up

1. Usually

monthly till 28weeks

fortnightly till 36weeks

weekly till EDD


2. Ask :

Date of visit: ….same as above…noted if any changes

Weight gain ,BP,Hb,urine protein,urine glucose,uterine size,

fetal movement

(primigravidae 18-20 weeks

multigravidae 16-18weeks

increase in frequency & intensity?)oedema?

This is her second pregnancy after 15years of no pregnancy. She is currently at 38 weeks

and 6 days of gestation. This pregnancyis unexpected but wanted. She had a period of

amenorrhea for four months but she did not expect for getting pregnant because of certain

reasons, 1) she had been having irregular menstruation after her first child, and 2) she is

obese and she only thought of having gained weight.

Her suspicion of a pregnancy was raised when she started having symptoms of pregnancy such as nausea

and morning vomiting episodes. She had a urine pregnancy test at POA 17 weeks at Klinik Kesihatan and

was tested positive.

Booking was done on 6th July 10 at POA 17 weeks. She was told that her BP was normal (120/83mmHg),

weighed 83 kg, height measured 150 cm, presence of edema, Hb normal (13.0gm/dL), blood group and

Rhesus was B+, VDRL and HIV non-reactive, absence of glycosuria or albuminuria. 2 doses of anti

tetanus toxoid were given, once in the end of September and October.

Patient took an MOGT test upon her 1st booking and results were normal, 4.4mmol/L; 2

nd hour

5.0mmol/L.

Patient had a weight gain of 6kg throughout the pregnancy, from 83kg-89kg. She claimed that her weight

was never drastic in nature, ie. not more than 2kg per week.

5. PAST OBSTETRIC HISTORY (POH)

Primigravida/ multigravida

Name the complicated one,then uneventful one.

If more than 3 children,

1. Summarize all the uneventful cases

How many boy and girl?

Weight range?

2. Contraceptive method

3. Pregnancy spacing (>2 yrs,consider ―normal‖; >5 yrs,why??voluntary?)


LIST THE PREVIOUS PREGNANCIES

1. Year of deliveries

2. The health institution for the delivery etc.

3. TYPE OF DELIVERIES ‐ SVD, LSCS

(elective?emergency?indication?counselling VBAC??

4. POA at delivery

5. antepartum : Any medical problems?

6. intrapartum : complication

7. postpartum : complication (fever?prolong stay in ward?wound

breakdown?PPH?blood transfusion?)

8. Babies ‐ weight, sex, abN, neonatal cx, alive/dead

9. breastfed – till when; bottlefed- why?

10. If miscarriage ‐ how many times?their POA, cause ?, ERPOC?

11. If previous extopic pregnancy – site of ectopic?how was it managed?

Eg. She had delivered 5 children between 1992 till 1997 which were all uneventful spontaneous

vaginal delivery with babies weight ranging between 2.8 to 3.5 kg. All the children were normal,

alive and well.

Eg. She delivered her 1st child back in year 1993 through SVD. The baby girl was a termed

child, weighing at 3.4kg. Her blood pressures and diabetes status were normal throughout, ie. no

history of PIH or GDM.

Patient received an episiotomy and the scar healed without complications. Apart from that, the

rest of the antenatal, intrapartum and post-partum history were all uneventful.

Eg. If the POH is complicated, give the main findings first.

CLERKING A COMPLICATED PAST OBSTETRIC HISTORY

Past h/o Miscarriage

‐ Which trimester was it ?

‐ Was it a confirmed pregnancy ? UPT/Ultrasound?

‐ Was any ERPOC performed ?

‐ Was there any complication such as infection / foul smelling PV discharge,

delayed period ?


Eg PRESENTING A COMPLICATED PAST OBSTERIC HISTORY –

h/o Miscarriage

She had delivered 5 children between 1992 till 1997 with a history of one

miscarriage in the third pregnancy.

The miscarriage at 9 weeks POA was a confirmed pregnancy diagnosed by

ultrasound. An ERPOC was performed and there was no complication following

the procedure.

The rest of the pregnancies were delivered by spontaneous vaginal delivery The

babies weights ranged between 2.8 to 3.5 kg. All the children were normal, alive

and well.

6. Past GYNAE / MENSTRUAL HISTORY

Menses

regular/irregular and what is the range ?

Formula = 12 ( 28−30𝑑

5−7𝑑 )

Pattern of menstruation : flow normal / minimal / heavy ?

( ask : clots ,flooding,wearing double protection?nocturnal soiling)

duration of flow ?

associated with dysmenorrhoea (menstrual pain?intermenstrual bleeding?)

Menarche?

Sexual Intercourse ‐ Any dyspareunia ? Superficial or deep ? postcoital

bleed?

Any other gynaecology problems such as PV discharge ?

Any pap smear done ?how many times?result?the date of last pap smear?

Previous history of subfertility? How long?frequency of intercourse

adequate?(normally,2 or 3 times a week or timed in relation to ovulation.)

Further consultation?result?

7. CONTRACEPTION HISTORY

Clerking the Contraception History

1. How many children does the couple wants ?

2. Is the family complete ?

3. What form of contraception are they practising or intend to use ? What have

they used before ?

4. Do you think their compliance can be assured ?


PAST MEDICAL / SURGICAL History

Past history of pre‐ existing diseases :

• Hypertension

• Thyroidism

• Blood diseases : anemia

• diabetes mellitus,

• asthma, COPD,

• heart disease,

• epilepsy,

• renal dss,

• venous thromboembolic dss,

• CT dss: SLE

• Infection : TB,hepatitis,rubella,HIV

• myasthenia gravis/myotonic dystrophy etc

Any relevant past history of hospitalization (including past operation done)

e.g appendectomy, hernial repair, Bowel operation etc

Mention the year of diagnosis

Mention the status of condition

Eg: Hypertension‐10 years on regular treatment

Diabetes type II – 6 years on dietary control

Have you ever suffered with your ―nerves‖?

Had u any problem with depression or the ―blues‖ after the birth? possible depression. During the past month, have you often been bothered by feeling down, depressed or hopeless? During the past month, have you often been bothered by having little interest or pleasure in doing things?

8. DRUG HISTORY

� Prescribed drugs

� Name, Dose, Duration or what is it for, what colour, how many times a day, how

long.

� On prescribe drugs (over the counter)

� Herbal or complementary therapy

� History of allergies to drugs

� Name of the drugs, what actually happens when patient took the drugs


� Rashes, swelling of face & difficulty breathing are important allergic reactions

� Nausea, vomiting or diarrhea are not necessarily allergic reactions

� Allergy to certain food?

9. FAMILY HISTORY

� Relevant family history of sibling and parents e.g Diabetic, hypertension, heart

disease, thromboembolic diseases,pre-eclampsia,psychotic psychiatric

disorder,twins, breast cancer, Ovarian cancer etc

� congenital abnormality

� Hereditary

10. PERSONAL & SOCIAL HISTORY

‐ education

‐ patient / husband’s age,occupation and income

-visited by husband?how many times/day?

‐ smoking, alcohol or drug abuse

‐ who is taking care of children

‐ recent travels

‐ domestic condition

‐ Sexual activity

Documents

History Clerking