- Introduction
- Introduction
• Appropriate introduction (full name + role)
• Establishes reason for visit
- Presenting compliant
- Presenting compliant
• First visit? Seen any other doctor? Any previous scans? And what were the results?
• Planned? Natural or IVF?
2a
• Dating history
i. LNMP
1. Add 9 months and 7 days
ii. Regular 28 day cycle
iii. Recent COCP use (up to 6 months before)
iv. Whether had dating scan (no)
v. Fertility treatment
2b
• Symptoms
i. nausea + vomiting,
ii. breast tenderness
iii. frequency
iv. Positive test? (how was the pregnancy confirmed - home test? Etc)
2c
• Problems
i. Any problems (pv bleeding, pain, rash)
- Obstetrics history
- Obstetrics history
• Parity and gravidity
• Number previous pregnancies
i. Duration (full term) , TOPs, miscarriages, ectopics - For above, how were they managed (ERCP?)
ii. Fertility treatment, multiple pregnancies and/or birth defects
• birth weight - mode of delivery (why? C section) - feeding type
• any complications with labour/delivery or previous pregnancies
- Past Medical History:
- past medical history:
• Major medical illnesses and treatment
• Surgical operations
- Gynae history
5. Gynae history • Fibroids • Polpys • adenomyosis • Surgery • Last cervical smear - when? Normal? • STD/HIV – STI check up?
- Drug history
- Drug history
• folic acid
• any regular medications
i. tetratogenics must be notified!
- Family history
FH • heart disease, hypertension and diabetes • Thromboembolic i. sickle cell disease • Pre-ecampsia • Psychotic
Genetic conditions
i. Pku
ii. Cf
iii. Thyroid disease
iv. MCADD (medium chain acyl coenzyme a dehydrogenase deficiency)
v. Congenital adrenal hyperplasia
- Social
• Partner
i. Married
ii. Long-term relationship
iii. Partner not involved
• Home
i. what is living situation like?
ii. Well supported at home?
iii. If previous deliveries - Who do other children live with?
• Work
i. what kind of work
ii. Support at work
iii. Financial worries?
• Lifestyle
i. Smoking and Alcohol
ii. Exercise
iii. Illicit drugs
- After History
What next:
- Blood test
- Dating scan
- Urine dip
- Screening test
- Elicits patient’s concerns and responds sensitively
- Invite questions
- Give booklets and leaflets
- Thank patient