History Taking and Physical Examination

Question 1

Demographics?

Answer 1

1. name
2. age
3. gravida - total number of pregnancies incl. current
4. parity + - total number of births >28 weeks + miscarriages/abortions < 28 weeks
5. gestational age - how it was determined
6. First day of LNMP
7. estimated due date - how it was calculated e.g. Negeles rule

Question 2

Presenting complaint?

Answer 2

State the MAIN COMPLAINT/S that made the client leave her home and go to a health facility and for how long?

Question 3

History of presenting complaints?

Answer 3

• Should be exhaustive as possible.
• Questions should be asked to confirm or exclude possible differential diagnoses depending on presenting complaints asking for symptoms and risk factors and any relevant information.
• Important positives and negatives should be included.
• Ask about pregnant moms well being
  > draining liquor?
  > per vaginal bleeding?
  > perceived fetal movements

Question 4

Review of other systems?

Answer 4

1. General
2. Genitourinary system (GUS) ; often fully tackled in HPC)
3. Gastrointestinal system (GIT)
4. Cardiovascular system (CVS)
5. Respiratory system (Resp)
6. Nervous system (NS)
7. Musculoskeletal system (MSS)
8. Skin

Question 5

Index pregnancy?

Answer 5

1. General health, tiredness, malaise, and other non-specific symptoms.
2. ANC visits (8 recommended)
   - Number, when and where was each visit, any problems found?
3. Tests
   – Blood tests; HIV, VDRL, Hb, Blood groups (ABO and Rhesus), Blood sugars, Hepatitis BsAg.
   - Urine tests; Pregnancy test, Protein, glucose,
   - UTI (Leucocytes, Leucocyte estarase and Nitrites)
   - BP and weight at each visit
   - Radiology e.g. USS
4. IPT (3 or 4 SP from second trimester), F/S, Albendazole, TTV, ITN, vaccination against Covid 19 and cholera.
5. Fetal movements if GA is more than 20 weeks.

Question 6

Past obstetrics history?

Answer 6

1. Number of deliveries including miscarriages and terminations.
2. For each delivery; when, where delivered, term/preterm, GA, BWT, mode of delivery, complications, dead/alive?
3. BPs and blood sugars in every pregnancy

Question 7

Past gynecological history?

Answer 7

1. Menarche
2. Menstrual cycle days - regular/irregular
3. Menstrual periods
4. Menstrual flow (Normal, heavy, scanty)
5. Dysmenorrhea (Primary, Secondary).
6. Intermenstrual bleeding or pain
7. Sex debut
8. Contraception use (type, since when, why stopped)
9. STI
10. Miscarriages; GA, complications
11. Screening for CaCx i.e, VIA, PAP smear
12. Previous gynecological procedures

Question 8

Past medical history?

Answer 8

DM,
Epilepsy,
Asthma,
Tuberculosis,
HTN,
HIV,
Psychosis,
Any related condition.

Question 9

Drugs allergies and intoxications?

Answer 9

Type, dosage, duration
Any allergies and severity, anaphylaxis or rash
Intoxication; smoking, drinking, illicit drugs.

Question 10

Past surgical history?

Answer 10

Any previous operations especially on the uterus including MVAs and Evacuations

Question 11

Family history?

Answer 11

HTN,
DM,
Twins on maternal side,
Pre-eclampsia, chromosomal/genetic/congenital malformation,
thrombophilias,
consanguinity,
anybody who has ever had that condition in her family.

Question 12

Social history?

Answer 12

Marital status, her and husband education status and occupation, residence, type of housing
Religion
Number of sexual partners, number of sex per week
Any dyspareunia and time in cycle ( infertility causes)
Plans for breastfeeding and child care arrangements.
Domestic violence screening
Please give a detailed social history if this is a teenage pregnancy.

Question 13

Summary?

Answer 13

Name,
Age
gravidity
parity
GA
HIV and VDRL
PCs and any strong positive/s.

Question 14

Obstetrics physical examination?

Answer 14

INSPECTION
VITAL SIGNS
HANDS
HEAD AND NECK
BREAST
CHEST
LUNGS
HEART
Obstetrics abdominal exam

Question 15

Summary of obstetric history and examination?

Answer 15

• Summarize relevant obstetric History and Examination.
• Name, Age, gravidity, parity, GA, HIV and VDRL, PCs and any strong positive/s, pink, nutritional status, vital signs, abdominal findings (SFH, lie, presentation, descent, FHR) and any significant positive findings.

Question 16

Gynecological physical exam?

Answer 16

INSPECTION
VITAL SIGNS
HANDS
HEAD AND NECK
BREAST
CHEST
LUNGS
HEART
Gynecological abdominal exam
Gynecological vaginal exam
Gynecological rectal exam

Question 17

Summary of gynecological istory and examination?

Answer 17

Summarize relevant gynecological History and Examination.
Name, Age, gravidity, parity, GA, HIV and VDRL, PCs and any strong positive/s. O/E pink, nutritional status, vital signs, abdominalpelvic findings and any significant positive findings.

Question 18

Problem list?

Answer 18

List down complaints from the patient and what you have established also on history and examination as problems from the patient.

Question 19

Differential diagnosis?

Answer 19

Depending on your history taking and physical examination, what do you think are the most likely differential diagnosis?

Question 20

Investigations?

Answer 20

With each differential diagnosis what investigations starting with bedside tests to more complex investigations can be ordered to confirm or exclude the diagnosis?

Question 21

Management plan?

Answer 21

How can you address the symptoms and signs of the patient?
How are the possible differentials managed?