HISTORY TAKING AND PHYSICAL EXAM

Pregnancy History and Analysis

Taking a comprehensive history of a present pregnancy, analyzing the main complaint, and gathering information about past obstetrics and gynecology history is crucial for understanding the patient’s medical background and providing appropriate care. Here is a step-by-step guide on how to conduct each part of the history:

1. Introduction and establishing rapport:
   • Introduce yourself and explain your role.
   • Create a comfortable and confidential environment.
   • Establish rapport and ensure the patient feels at ease.
2. History of present pregnancy:
   • Confirm the pregnancy status and estimated gestational age.
   • Determine the reason for the visit and the main complaint.
   • Obtain information about the current pregnancy, such as:
     • Date of the last menstrual period (LMP).
     • Any history of irregular menstrual cycles or previous fertility issues.
     • Details about the confirmation of pregnancy (home test, clinic test, ultrasound, etc.).
     • Any pregnancy symptoms, such as nausea, vomiting, fatigue, or breast changes.
     • Any vaginal bleeding or spotting during the current pregnancy.
     • Any history of chronic medical conditions or medication use during pregnancy.
     • Note the patient’s understanding and expectations regarding the current pregnancy.
3. Analysis of the main complaint:
   • Focus on the specific reason the patient is seeking care.
   • Gather details about the complaint, such as:
     • Duration, severity, and progression of symptoms.
     • Factors that exacerbate or alleviate the complaint.
     • Any associated symptoms or concurrent medical issues.
     • Impact on the patient’s daily life and activities.
   • Employ open-ended questions to allow the patient to express their concerns fully.
4. Past obstetrics history:
   • Inquire about the patient’s previous pregnancies, if applicable:
     • Number of pregnancies and outcomes (live births, miscarriages, stillbirths, abortions).
     • Complications during previous pregnancies (gestational diabetes, preeclampsia, etc.).
     • Mode of delivery (vaginal, cesarean section) for each pregnancy.
     • Birth weight of the infants.
     • Any history of preterm labor or premature rupture of membranes.
     • Any neonatal complications or congenital abnormalities.
   • Discuss the patient’s experiences with breastfeeding, if applicable.
5. Gynecology history:
   • Explore the patient’s gynecological background:
     • Menarche (age at first menstruation) and menstrual cycle regularity.
     • Any history of abnormal uterine bleeding, such as heavy or prolonged periods.
     • Previous use of contraception methods.
     • History of sexually transmitted infections (STIs) and treatment.
     • Any history of gynecological surgeries or procedures.
     • Pap smear history and results.
     • Any current or past gynecological conditions (endometriosis, fibroids, etc.).
     • Note the patient’s family history of gynecological conditions, if relevant.

Throughout the history-taking process, be attentive, empathetic, and respectful. Use appropriate medical terminology, but ensure that the patient understands the questions and provides accurate responses. Encourage the patient to ask questions and address any concerns they may have. Remember to maintain patient confidentiality and adhere to ethical guidelines.

 

Obstetrics Terms

Here are some common obstetrics terms and their definitions:

1. Parity: Refers to the number of pregnancies a woman has had beyond 20 weeks of gestation, regardless of the outcome (live birth, stillbirth, or miscarriage). It is often expressed using a numerical system. For example, nulliparous means a woman who has never had a pregnancy beyond 20 weeks, primiparous means a woman who has had one pregnancy beyond 20 weeks, and multiparous means a woman who has had multiple pregnancies beyond 20 weeks.
2. Gravida: Indicates the total number of times a woman has been pregnant, regardless of the outcome. This includes both current and past pregnancies, including stillbirths, miscarriages, and induced abortions.
3. Nulligravida: A woman who has never been pregnant.
4. Multigravida: A woman who has been pregnant more than once.
5. Primigravida: A woman who is pregnant for the first time.
6. Term: Refers to a pregnancy that has reached full-term, typically 37 to 42 weeks.
7. Preterm: Describes a pregnancy that ends before 37 weeks of gestation.
8. Post-term: Indicates a pregnancy that lasts beyond 42 weeks of gestation.
9. Abortion: In obstetrics, abortion refers to the loss of a pregnancy before 20 weeks of gestation. It can be further classified as a spontaneous abortion (miscarriage) or an induced abortion (intentional termination).
10. Gestational age: The age of a pregnancy, typically measured in weeks from the first day of the last menstrual period (LMP) or estimated through ultrasound examination.
11. Gravidity: The number of times a woman has been pregnant, including both ongoing and completed pregnancies.
12. Antenatal care: Medical care and monitoring provided to pregnant women before the birth of their child to ensure the well-being of both the mother and the baby.
13. Braxton Hicks contractions: Irregular, painless contractions of the uterus that occur during pregnancy, often in preparation for labor.
14. Crowning: The stage of labor when the baby’s head starts to emerge from the birth canal during vaginal delivery.
15. Meconium: The first stool passed by a newborn. It is typically thick, sticky, and greenish-black in color.

These are just a few obstetrics terms to get you started. Obstetrics is a vast field with many more specialized terms and concepts.

 

Obstetrics Exam Guide

 

Gynecology Exam Overview