A Guide To ObGyn Case Presentation

OBSTETRIC HISTORY I

For a patient who presents with a complaint

Associate Professor Dr Hanifullah Khan

The importance of a good history

Introduction This section details the key points of a clinical history

The Importance of Patient History

A large percentage of the time, a diagnosis can be made based on the history alone

The critical first step in determining the aetiology of a patient's problem

A carefully taken history – provides a clinical guide for the P/E to follow

2 Purposes

Provide a synopsis of background

risk!

An account of the progress

of the pregnancy

Proper SequenceHistory should be taken & presented in a logical

sequence

Mandatorily, the initial sequence must include !

• CC, HOPI, HOCP & HOPP in that order, !

• although HOPI and HOCP may be combined if required

• Chief complaint!• History of present illness!• History of current pregnancy!• History of past pregnancy

• Gyn/ob history!• Past medical /surgical history!• Family history!• Drug /blood transfusion history!• Social history

The other components!• then follow, but may be

rearranged in order of relevance to the HOPI or HOCP

This is an actual student history

Sample History

always begin with chief complaint

there is only 1 patient history,

although it contains many sections

do not use titles for each

section, instead use paragraphs

The history should be as

short as possible - make

intelligent use of descriptive

words & avoid irrelevant & unnecessary

words. Do not repeat

information

the major portion of the

history should be the history of current illness

!This is an actual student

presentation!!

This is the main reason the patient has come to see you The Chief Complaint

Usually a single symptom, !

occasionally more than one complaint eg: chest pain, palpitation, shortness of breath

The patient describes the problem in their own words

It should be recorded as such

Must have duration of problem!

Short/specific in one clear sentence

• Elaborate on the chief complaint in detail • Ask relevant associated symptoms • Have differential diagnoses in mind

History of Current Illness

1.Demographic info!

2.Primary history !3.Associated

symptoms!4.Symptoms of any

complications

Components of HOCI

• Always relay story in duration (e.g. “the patient was apparently well until 1 day prior to admission”) and NOT time (e.g. last Wednesday or in July)!

• If the patient has > 1 symptom, !• take each symptom individually and !• follow it through fully !• mention significant negatives as well!

• Avoid medical terminology

Components of HOCI!1. Demographic

info!2. Primary

history !3. Associated

symptoms!4. Symptoms of

any complications

Demographic Information

Gravidity - no. of pregnancies!including current pregnancy!(regardless of the outcome)!Parity - no. of births beyond !

24 wk gestation

Name, age , gravidity, parity, LMP, EDD

Appropriate to begin with a summary of the details

*Actual student history - grammar, context and other features can be improved!

Components of HOCI!1. Demographic

info!2. Primary

history !3. Associated

symptoms!4. Symptoms of

any complications

Primary History

Elaborates on the main complaint & deals with the chronology & the characteristics

of the chief complaint

Describes the onset, course, severity and duration of the chief

complaint

Some features of the 10 Hx!• Anatomic location!

• Quality!

• Quantity or severity!

• Timing!

• Setting in which the symptoms occur!

• Aggravating or relieving factors

Note that not all questions may be relevant for a symptom, e.g. a location cannot be determined for “difficulty in breathing”

Components of HOCI!1. Demographic

info!2. Primary

history !3. Associated

symptoms!4. Symptoms of

any complications

Associated Symptoms

May serve as a general review of systems

Information gathered here serves to: !

• support the diagnosis !• gauge the severity of the

disorder

Examples

❖ if a pt ℅ abdominal pain - must ask for presence or absence of nausea and vomiting!

❖ if a pt ℅ vaginal bleeding - per vaginal discharge, pruritis or

Components of HOCI!1. Demographic

info!2. Primary

history !3. Associated

symptoms!4. Symptoms of

any complications

Symptoms of Complications

This will help in the subsequent management

of the pt

Again, this helps to confirm the diagnosis & assess the severity of the problem

Examples

For complaint of dysuria & increased frequency of micturition - loin to

groin pain, backache & fever; might suggest ascending infection

complicating the UTI

The Complete HOCI

Please do not forget this…

REMINDER!!

The most elaborate and largest component of a patient history is the history of current

illness.!!

All other components should be concise and serve as supportive information for the

history of current illness.!

Antenatal history or…

History of Current Pregnancy

In which you assess the status of the current pregnancy and its connections to the current illness

The HOCP

Should have a !few components

Should be a chronological & concise account (1st, 2nd & 3rd trimesters)

Confirmation of pregnancy

Comorbidities

Results of ultrasound scans

Antenatal booking & results of tests

1. Confirmation of pregnancy

❖ assessment of menstrual period!

❖ urine pregnancy test (UPT)!

❖ assessment of symptoms!

❖ early ultrasound scan

This can be done in a number of ways

Calculation from LM

Assessment of menstrual periodAccuracy is reliant on a few points:!• must be measured using 1st day of LMP!• periods must be regular of 28 day cycle!• the pt must be sure of the LMP!!Calculation of dates is inaccurate if any of these conditions are unfulfilled

The gestational date can be calculated from the last menstrual period (LMP) using Naegele’s rule

Urine test

UPT

Subjective test - it doesn't quantify gestation but may suggest the duration of pregnancy!!Not very specific nor sensitive - false positives are common

Becomes positive around 5 weeks of gestation

The occurrence of pregnancy symptoms…

Assessment of Symptoms

Quickening - the first sensation of fetal movement :!

primigravida - felt between 22-23 weeks!multigravida - felt between 16-18 weeks

may indicate the gestation & provide a rough guide to the accuracy of the menstrual dates

Common early pregnancy symptoms are nausea, vomiting,

gastric symptoms & general malaise:!

noticeable between 5-6 weeks gestation!

usually quite accurate!absence of symptoms is not

predictive of feral well-being

These symptoms become important to confirm gestation

if an early ultrasound scan was not done

Done within the first 12 weeks of gestation…

Early Ultrasound ScanEvery early scan must answer at least 3 questions - the number of fetuses, their health (viabilty) & the gestation!!A simple scan is used to measure the Crown-Rump Length (CRL) for accurate dating!!Always ask the patient if she has had one & confirm the above 3 questions

provides the most accurate assessment of gestational dates. Every mother should be encouraged to have one.

2. Antenatal booking & results of tests Determine precisely!❖ the booking Haemoglobin (Hb)

- the occurrence of physiological anaemia in later trimesters masks the actual blood content!

❖ the booking Blood Pressure (BP) - this is to determine if the patient has preexisting hypertension (H/T)!

❖ if screening for diabetes mellitus (DM) was done & the results

Early booking - important to determine the initial well being of the mother as

well as for assessment of potential risks!The 1st trimester is the time when the patient is closest to the non-pregnant

state!Subsequent hormonal & physiological

alterations tend to mask findings & may confuse patient assessment

Other antenatal tests - Hepatitis screen, VDRL, HIV - should just be mentioned as normal & need not be

elaborated

3. Results of ultrasound scans❖ The early u/s scan is

considered the gold standard for fetal dating!

❖ The 2nd trimester u/s scan - assessment of feral anomaly!

❖ 3rd trimester scan - placental site, confirm lie & liquor & size

It is important to ask the pt about any scans done!

An early scan is one done prior to 14 weeks

gestation

Ultrasound scanning is part & parcel of modern obstetric practice. All

mothers should have access to this

4. ComorbiditiesThe commonest are DM &

Hypertension (H/T)!The incidence of preexisting disease is increasing & it is common to find

mothers getting pregnant with them

Other important comorbidities include anaemia & thyroid disease

❖ Late pregnancy disease usually affects growth & well-being

❖ Differentiation between early & late pregnancy disease is crucial!

❖ Early pregnancy disease has implications on fetal development

This is a sample of the HOCP. It should not be too long and contain all the necessary information.

Confirmation of pregnancy

Investigations during booking

Ultrasound scans Screening for comorbidities

Previous pregnancies and deliveries …

History of Past Pregnancy (HOPP)

What happened in the past may indicate the cause of the current problem as well as impact the current pregnancy

Summarize significant points❖ Any significant ante-, intra-

or postpartum events!❖ miscarriages & their

outcomes!❖ Life & health of the baby!❖ Contraception – Type,

when begun, why stopped, any side effects!

❖ Did the current complaint occur in past pregnancy?

Not necessary to present everything!

An early scan is one done prior to 14 weeks gestation

❖ Modes of delivery, baby gender & birth weights need not be presented individually

This student has combined the gynae/menstrual history with HOPP,

perfectly acceptable & useful

Additionally, breast feeding (BF) should be asked for, &

reinforced as a positive attitude

BF is also significant, as many women have amenorrhoea or

abnormal periods due to hyperprolacinaemia which may

impact the accuracy of dates

All the other stuff

Other components These components provide supportive evidence for the possible diagnosis

Remember this?History should be taken & presented in a logical

sequence

Mandatorily, the initial sequence must include !

• CC, HOPI, HOCP & HOPP in that order, !

• although HOPI and HOCP may be combined if required

• Chief complaint!• History of present illness!• History of current pregnancy!• History of past pregnancy

• Gyn/ob history!• Past medical /surgical history!• Family history!• Drug /blood transfusion history!• Social history

The other components!• then follow, but may be

rearranged in order of relevance to the HOPI or HOCP

The last part of the history

Rearranged according to relevance

These histories support the HOCI!

!They should be brief!

!Questions asked the patient

should be relevant to the current problem or associated

with the management

• Gyn/ob history!• Past medical /surgical history!• Family history!• Drug /blood transfusion history!• Social history

The rest of the component histories are arranged

according to their relevance to the patient’s problem

An example

This is an abbreviated example of the other histories with relevance to the patients problem!

!Some questions such as family history of diabetes and hypertension are

universal - they are relevant irrespective of the complaint due to the global impact of the disease!

!Socioeconomic history serves to elaborate the status of the patient with

particular relevance to communicable disease!

Most people consume alcohol but are not dependant on it; it

is wrong to use the term alcoholic ulnless there is

evidence of substance abuse

This is the HOCI!This should be the largest component

of the history

This is the HOCP & HOPP!

This should follow the HOCI

The other histories!

Make up the smallest portion of the full history

Any component history that is contributory to the diagnosis and significant, should be made part of the HOCI

Happy Clerking!