OBSTETRICS | HISTORY TAKING

Dr. Frances Janine Vera Cruz |Lecture Date: March 22, 2021 | 2nd SEM

OVERVIEW:
laboratories to come up with the
I.Before the Start of Interview
II. Parts of History Taking diagnosis, hence, this will give us the
A. General Data management for the patient.
B. Chief Complaint  This is a very important step,
C. Past Medical History sometimes during the history taking,
D. Family History you will already know the diagnosis
E. Personal and Social History of the patient.
F. Menstrual History  Identify the Patient
G. Sexual History  “What is your full name?”
H. Contraceptive Use  Don’t say the name of the patient
I. Gynecologic History
 Establish Rapport
J. Obstetric History
K. Prenatal History  Maintain eye contact
L. History of Present Illness  Be courteous
M. Review of Systems  Show empathy (show that you
III. Physical Examination understand the patient’s situation)
IV. Assessment  Make it personal (get to know your
V. Samplex patient)
 Listen actively
 Keep your word
BEFORE THE START OF INTERVIEW
PARTS OF HISTORY TAKING
 Gather your equipments
GENERAL DATA
 Name:
 Age:
 Marital status:
 Nationality:
 Religion:
 Date & Place of birth:
 Address:
 If admitted (# of times admitted at the
 Make sure they are functional and
institution):
complete
 This is a case of L.R., a 25 year old female,
 In OB, you will need the tape measure,
married, Filipino, Roman Catholic, born on
stethoscope, BP apparatus, and when you
March 4, 1996 in Sampaloc, Manila. She is
do the physical examination, you will also
currently residing at Vigan, Ilocos Sur.
have your gloves.
Admitted for the 1st time at our institution
 Introduce Yourself
(March 22, 2021 at around 3:00pm)
 “Good morning ma’am, my name is
Frances Vera Cruz and I am a
 We don’t disclose the patient’s name; use
medical student from UNP. I will be
the initials as patient identifiers.
asking questions with regards to your
complaint and after this I will perform
 Sometimes, we need to know the religion.
a physical examination.”
 Explain your Purpose Why? Because there are patients like
 “This interview will help us come up Jehova’s witness, they don’t do blood
with a diagnosis, so as we could transfusion; Muslims, they will get the
address your complaint.” placenta.
 We should have the differentials so
that we can do the different

Trans 4.0| MARTINEZ| MEJOS | MENGUITA| MONTESCLAROS | OCTAVIO Page 1 | 6

 CHIEF COMPLAINT  (-) Asthma, (-) Thyroid disorders, (-) CHVD, (-
) Diabetes Mellitus, (-) Hospitalization
 The MAIN reason why she sought consult at
the hospital: what made them come to
 The woman should be asked to list any
you/ to ER/OPD
significant health problems that she has
 These are the main chief complaints of the
had during her lifetime, including all
OB patients: hospitalizations and operative procedures.
 Labor pains- pt is already nearing It is reasonable for the physician to ask
labor/term about specific illnesses, such as diabetes,
 Watery vaginal discharge- ask them if hypertension, or heart disease, that seem
it’s really watery or just mucoid. If it’s likely based on what is known about the
mucoid → Bloody show woman or about her family history.
 Vaginal bleeding- pure blood or with  Medications taken and reasons for doing
blood clots. Bloody show- more on so should be noted, as should allergic
blood but with mucoid discharge. responses to medications.
 Elective cesarian section- for patients
who have previous cesarean sections,
FAMILY HISTORY
we usually schedule them between 38-
39 weeks. That’s the chief complaint
● Diabetes
because at the OPD, we are the one
who set the date for the admission at ● Cancer (specially of reproductive organs)
the hospital. ● Hypertension
 Decreased fetal movement → IUFD, or ● Asthma
immediately get FHT, save the baby if ● Heart diseases
there’s heartbeat. ● Thyroid diseases
● Congenital anomalies in the family- for the
PAST MEDICAL HISTORY early weeks of the pregnancy (1st, 2nd
 Medical conditions: trimester), if the patient has a high history of
 When was it diagnosed congenital anomalies, we have to request
 Maintenance medications- put the
for congenital anomalies scanning.
dosage, frequency and how long she
has been taking them, if she takes them
● (+) Hypertension- mother
regularly or misses a dose.
● (+) Diabetes- father
 Previous surgeries or hospitalizations: ● (-) Asthma, (-) Cancer, (-)Pulmonary
 Take note of the year and name of Tuberculosis, (-) Anemia, (-) Heart Disease
hospital
 Esp. if these are previous cesarean ● Ask about the genetic and family history of
sections, we have to get the operative the patient and her partner and/or father.
technique. Put the main reason of the What are the ethnic backgrounds of the
surgery, name of hospital, year of the
patient and father? Is there any family
operation.
 For hospitalization: ex. On this current history of genetic diseases such as sickle
pregnancy, she was hospitalized on her cell anemia, cystic fibrosis, or muscular
second trimester for dizziness. She had dystrophy, among others? Have babies in
anemia so she was transfused with the family had any congenital problems?
blood.
 Put the date for previous hospitalization, PERSONAL AND SOCIAL HISTORY
the reason, and how many days she
was admitted.  Line of work
 (+) Hypertension- since 2019 (Regular intake
 important to know if patient has
of Amlodipine 5mg once a day)
exposure to radiation such as

Trans 4.0| MARTINEZ| MEJOS | MENGUITA| MONTESCLAROS | OCTAVIO Page 2 | 6

 factory workers, radtechs, or those EXAMPLE
who work on cancer instituition that
handles cancer drug
 Age of husband
 Length of marriage
Menarche – 13 years old
 History of smoking, alcohol use, illicit drug
Interval – regular (monthly)
use
Duration- 3 to 4 days
 Allergies (food/medications) Amount- first day 4-5 pads fully soaked (Thick
red line), second and third day 4-5 pads
EXAMPLE moderately soaked (Thinner line). 3 pads with
 Patient works as a make-up artist, married minimal bleeding on the succeeding days,
for 3 years to a 28 year old photographer. (last dot lines is spotting)
patient is a non-smoker, previously an Symptoms- dysmenorrhea on the first day
occasional alcoholic beverage drinker, SEXUAL HISTORY
with no known allergies to food and drugs
Coitarche

 “previously” means that the patient  When was her first sexual intercourse
isn’t drinking during her time of (age)
pregnancy  Number of sexual partners
 Especially for patients who have
FOR SMOKING PATIENTS
history of STI during pregnancy
 pack years= (cigarettes per day/ Pack  Symptoms during or after sexual
size(20)) x No. years intercourse
 Dyspareunia, post-coital bleeding,
EXAMPLE foul smelling discharge after sexual
 (10 cigarettes per day/ 20 pack size) x 2 = 1 intercourse
pack year EXAMPLE
 Coitarche – 20 years old
 (12 cigarettes per day/ 20 pack size) x 8 =  Number of sexual partners – 2
4.8 pack years  Symptoms during or after coitus – None

MENSTRUAL HISTORY CONTRACEPTIVE USE

M.I.D.A.S. Previous contraception used (note year and

 M- Menarche duration)
 I- Interval (regular (monthly)  Oral contraceptive pills (OCPs) – very
 D- Duration (days) common
 A- Amount  Injectables (examples are DMPA – depot
 Consuming ___ pads per day on medroxyprogesterone acetate)
heaviest days  Implanon (the one you put in the inner side
 S- Symptoms of the non-dominant upper arm, toothpick-
 Headache, mood changes, breast sized)
tenderness, interference to daily  IUD
living  History of Previous tubal ligation
 Dysmenorrhea- note duration,  Barrier methods (condom, female cup)
intensity, frequency, relief measure  Fertility awareness-based methods
 LMP (calendar, basal body temperature,
 PMP cervical mucous method – Billing’s method,
lactation amenorrhea – if the patient is still
breastfeeding)

Trans 4.0| MARTINEZ| MEJOS | MENGUITA| MONTESCLAROS | OCTAVIO Page 3 | 6

Example: Example:
 Previous contraception used YEAR MODE OUTCOME
 Oral contraception use – (Diane is an oral G1 2019 NSD Alive boy
contraceptive pill) April – June 2020 G2 Present
 Condom – irregular use G3 -
You also have to take note if the patient is Summary: G2P1(1001)
taking OCPs everyday because if missed, she
could get pregnant.
PRENATAL HISTORY
GYNECOLOGIC HISTORY You have to put everything
 1st consult then subsequent consults. You
 Previous Pap Smear results (year) indicated do not need specific dates.
here if there is dysplasia, ASCUS  Labs and UTZ (ultrasound) done (note
 Recent gynecologic procedures remarkable results) if normal, you just put
 Sexually transmitted diseases “all labs were normal”
 Pelvic inflammatory diseases  Medications taken (dose, frequency,
 Vaginal infections duration) not just the antibiotics but also
Example: the maintenance medications for example,
 Pap smear done January 2019 – Result: no folic acid, ferrous sulfate, calcium, other
dysplasia multivitamins, also if the patient is taking
 No previous gynecologic procedures done maternal milk like Anmum and how many
 No known STD, PID, or vaginal infections times she’s taking it.
Consultations: you have to put who does the
OBSTETRIC HISTORY consultation because there are a lot of patients
especially in provinces, they only go to the local
Gravidity- total number of confirmed pregnancies
that a woman has had regardless of the outcome health centers.
 Nurse, midwife, general practitioner, OB-
Nulligravida – a woman who currently is not
pregnant and has never been pregnant. GYN
 Hospital, health center, clinic, lying-in
Gravida – a woman who currently is pregnant or
has been in the past, irrespective of the centers
Example:
pregnancy outcome.
With the establishment of the first pregnancy, she  At 5th week of amenorrhea, patient
suspected pregnancy. PT home kit
becomes a primigravida, and with successive
revealed a positive result which prompted
pregnancies, a multigravida.
Parity – the number of births that a woman has her to seek consult at the local health
center. CBC and UA were normal. She was
had after 20 weeks gestation
Nullipara – a woman who has never completed a started on folic acid once a day.
 2nd consult (14 weeks) – She sought consult
pregnancy beyond 20 weeks' gestation. She may
not have been pregnant or may have had a at a private OB. FBS, HbsAg, VDRL and HIV
testing, and ultrasound were done. For UTZ,
spontaneous or elective abortion(s) or an ectopic
you can put the weeks because it’s gonna
pregnancy
Primipara – a woman who has been delivered differ with the LMP, so you know the week
difference between the LMP and the UTZ.
only once of a fetus or fetuses born alive or dead
with an estimated length of gestation of 20 or Then you also have to know the weight,
position, and presentation of the fetus.
more weeks
Multipara – a woman who has completed two or Always check the amniotic fluid in the UTZ
and the placenta if it is anterior high lying
more pregnancies to 20 weeks' gestation or more.
because we don’t want placenta previa.
(TPAL)
 Term births HISTORY OF PRRESENT ILLNESS
 Preterm births
 Abortions, H-mole, Ectopic pregnancies ONSET OF SYMPTOMS (Days/weeks prior to
admission)
 Living

Trans 4.0| MARTINEZ| MEJOS | MENGUITA| MONTESCLAROS | OCTAVIO Page 4 | 6

 Example the patient will tell you about labor organ system, the might remember mentioning
pains; so when did this labor pain started. about it
Example 8 hours prior to admission, labor pain  Helps in eliciting a medical history from a
started. patient
 State the chief complaint  Focuses on the subjective symptoms
 What are the accompanying symptoms perceived by the patient
Example neto if accompanied ba ng bloody Note: it was mentioned before that never do a
mucoid discharge thorough review of system if in emergency or in
 Efforts done to treat the symptoms active labor. You can delay this or continue in the
This one naman if nag take ba ng pain reliever ward.
or my mga nilagay ba na liniments or did she
PHYSICAL EXAMINATION
sought consult to a local health center or a
private OB Examples of output. But focus on the
 Medications taken abdomen and pelvic examination. Know your
Leopold’s manuever so you will know where to
LABOR PAINS find your FHT.
 Onset (start) Remember again if you are at the ER, be
 Intensity (mild, mod, strong) selective of what you will ask lalo pa if nag
 Frequency of uterine contractions (how many seseizure na ang patient. You can just ask the
in a minute or an hour, example every 5 important questions.
minutes) If you are in an OPD you can do your
 Duration example 30 seconds ganun (how thorough assessment. Yung GTPAL (gravida,
long is each contraction last) Term, premature, Abortion, Living) make sure
 Is it relieved by rest, walking, or change in you know how to do it.
positions?  General survey-
 Or was the contractions synchronous with Fetal  Mental status
movement  Skin color/condition
 Hygeine
VAGINAL DISCHARGE/ BLEEDING  Posture and gait
 Onset  Body build
 Appearance (Bloody/clear/stained)  Vital Signs
 Consitency (watery/mucoid)  BP, HR, RR, Temp
Yung urine you can control it, pero if it is  Skin
amniotic fluid usually derederetso yan without  Warm to touch, skin turgor, lesions?
you controlling it  Head and Neck
 Amount (you have to indicate like if estimated  Anicteric sclera
ilang ml or like almost one cup full ba)  Pink palpebral conjunctivae
 Continuous?  No nasoaural discharge
 Is it aggreviated by bearing down? If the  No tonsillopharyngeal congestion
bleeding also is accompanied with uterine  No cervico lymphadenopathy
contractions? It could be a sign of abruption  Chest and LUngs
placenta (premature separation of placenta  Symmetrical chest expansion
from uterus)  No chest retractions
ELECTIVE CASES  Clear breath sounds
 Reason for CS  CVS
 Last consultation (ask kung sino ang OB niya or  Adynamic precordium
who made a schedule for her)  Rate and rythm
 Murmurs
REVIEW OF SYSTEMS
 Abdomen
 Arrange by organ system because sometimes  Globular
the patients tend to forget mentioning about  Fundic Height (FH): 30 cm
other symptoms, but when you ask them by  Fetal Heart Tone (FHT): 140bpm LLQ (left
lower quadrant)

Trans 4.0| MARTINEZ| MEJOS | MENGUITA| MONTESCLAROS | OCTAVIO Page 5 | 6

  EFW (estimated Fetal weight): 3.3-3.5 kg Matching Type 2:
 Contractions: 4 mild contractions q 3
1.30seconds each contraction
minutes 2.Contractions every 10 minutes interval
 Perform Leopold’s Manuever 3.Mild contraction
 Extremities A. Duration
 Edema (bipedal, pitting) B. Intensity
ASSESSMENT C. Frequency

 Gavidity and Parity (TPAL) TRUE OR FALSE

 Age of gestation 1. Ectopic pregnancies are counted as preterm
 Presentation births in TPAL.
 In labor or not 2. Specific dates of consult are needed in
 Other medical conditions prenatal history.
3. State the name of the patient.
4. Maintain eye contact and show empathy.
5. Before you start the interview, make sure all your
equipments are functional and complete.

MCQ
1. Total number of confirmed pregnancies that a
woman has had regardless of the outcome
A. Gravidity
B. Parity
C. Nulligravida
D. Nullipara
2. The number of births that a woman has had
after 20 weeks’ gestation
A. Gravidity
B. Parity
C. Nulligravida
D. Nullipara

IDENTIFICATION:
Example: 1. P in TPAL stands for? Parity or preterm?
*Gravida 2, Para 1 (1001) 2. How to locate the fetal heart tone?
*Age of gestation 35 wks Pregnancy uterine 3. Normal rate of fetal heart tone?
*Ultrasound - cephalic presentation 4. Proper recording of fetal heart tone.
*Came in due to preterm labor 5. How to get the fundic height?
*Include the medical conditions; example she has 6. Susan is in her 4th pregnancy. Her first pregnancy
DM, asthma. HPN, anemia, or etc. ended in a spontaneous abortion at 8 weeks, the
second resulted in live birth of twin boys at 38 weeks,
SAMPLEX and the 3rd resulted in a live birth at 34 weeks.
Matching Type 1:
1. Menarche
2. Alcohol use
3. Age of Husband
4. Coitarche
5. Number of sexual partners
Rationale. Always count multiple pregnancies as one in all categories except in Living children.
6. G4, T1, P1, A1, L3
6. Consumed pads per day 5. Put the tape measure starting from the pubic bone to the fundus
4. Example: 125bpm @ RUQ (right upper quadrant)
3. 120-160bpm
A. Past medical History stethoscope or the doppler on the fetal back near the cephalic part
B. Personal and social History
2. put your palms on the sides and locate for the fetal back (2nd leopold’s manuever); put the
1. Preterm
C. General Data IDENTIFICATION:
D. Menstrual history 6. D

E. Sexual History
5. E 5. T
4. E 4. T
3. B 3. B 3. F- Ask the full name of the patient and don’t state it
2. B 2. C 2. B 2. F- (You do not need specific dates)
1. D 1. A 1.A 1. F- (Ectopic pregnancies are included in abortions in TPAL)
MT 1: MT 2: MCQ T/F

Trans 4.0| MARTINEZ| MEJOS | MENGUITA| MONTESCLAROS | OCTAVIO Page 6 | 6