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History taking

1) Patient Profile
Name

RN:

Age

Bed:

Race

Religion

Gravida

Parity

Abortion

LMP

EDD

POA

Residence
Occupation

Admitted date
2) Chief complaint + Duration

3) History of present illness


c/o

Pd

Dd

s/s

Severity
Medication

Risk factors

Causes

Remarks

Mild/ moderate/ severe

4) History of present pregnancy


1st trimester
Booking
Minor ailment
Bleeding
Physical Examination

Investigations

Height

Weight

Hb

Urine routine

Bloog group

BP

MOGTT

Hept. B

HIV

VDRL

Height

Weight

BP

Weight

BP

Ultrasound (Dating scan)


Medications? (vit, iron
tablets, folic acid..)
Remarks
(Planned/Unplanned)
2nd trimester
Minor ailment
Bleeding
Physical Examination

Uterine size

Quickening
MOGTT
Ultrasound (Anomaly
scan)
Development of illness

Nuchal thickness :

Tetanus toxoid
Medications
Remarks

3rd trimester
Minor ailment
Bleeding
Height
Physical Examination
MOGTT
Ultrasound
Remarks

Uterine size

5) Past obstetrical history


G

Year

Type of labour
(SVD, LSCS,
Vacuum, etc...)

Pregnancy
(Full / Pre)

6) Menstrual history
Menarche
:
Menstrual cycle
: Regularity

Antenatal period
complication

: Regular / Not

Duration of flow

Cycle length

Contraceptive History :
7) Gynaecological history
History of suggestive STI

Any gynaecological problem

Past medical history

Past surgicall history

Family history

:Maternal
Paternal
Siblings

8) Personal history
Diet history

Sleep

Bowel bladder habit

Social history

: Marital status :

Vegetarian / non vegetarian

Drug history

Spouse

Occupation

Education

Income

Basic needs

:
Any allergic (
)
Traditional Medication (

Smoking/Alcohol
Others

Health of baby
(G, Weight,
A/D)

Breast
Feeding

Remarks

Physical examination
General examination
Remarks
Built

Small /average/ large

Nourishment

Thin / obese

BMI

Weight:
Height:

Vital parameters

BP

Eyes

Pallor

Temp
Icterus

Pallor

Mouth

Icterus

Oral hygiene

Bleeding in teeth and gums


Neck

Thyroid enlargement
Finger clubbing

Hand & Nail

Nail colour

Capillary filling time

Koilonychia/ platynychia
IV Cannula / IV fluid

Breast
Leg

Varicose vein

Edema

Remark

Systemic examination
1) Cvs
: Pulse rate

Heart rate

Heart murmur

Blood pressure

Heart beat

: normal / tachycardia / bradycardia

2) Respi

: Respiratory rate
Breathing

:
:

Abdominal examination
1) Inspection
I.

Abdomen distended by gravid uterus

II.

Evidence of linea nigra

III.

Stretch mark
a. Stria gravidarum

b. Stria albicans

IV.

Scars :

site

Size

Healing

Hernia to scar :
V.

Umbilicus

VI.

Fullness of flank

VII.

Fetal movement

VIII.

Quadrant movement

Inverted (

Everted (

2) Palpation
I.

Enquire of pain

II.

Superficial palpation

III.

Clinical fundal height

IV.

Leopolds maneuvers
a) Fundal grip

b) Right Lateral grip

c) Left Lateral grip

d) 1st pelvic grip

e) 2nd pelvic grip

A. Fetal Head Hard globular mass / Hard globular mass which is ballotable suggestive of fetal head.
B. Fetal Breech Broad smooth irregular mass suggestive of fetal breech.
C. Fetal Back Smooth curved broad surface suggestive of fetal back.
D. Fetal Limbs Small irregular knob like sturcture suggestive of fetal limbs.

3) Auscultation for fetus heart sound :

Discussion:

Remarks: