HISTORY TAKING ( OBSTETRICS )

1. Particulars of the patient : Particulars of the student :

 Name :
 Age :
 Father's/ Husband's name :
 Occupation : Particulars of Hospital :
 Religion :
 Address :
 Date of Admission :
 Date of Examination :

2. Chief complaints : According to duration & severity of disease.

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3. History of present illness :

4. Obstetric history :

 Married for
 Para
 Gravida
 Abortion/MR
 Mode of Delivery
 Age of last child
5. Obstetric chart:

6. Menstrual History :

 Age at Menarche
 MP
 MC
 LMP
 EDD
 Dysmenorrhea

7. History of Past Illness

8. Socio-economic history

9. Family history

10. Drug history

11. Personal history

12. Immunization history

13. Contraceptive history

14. General Examination

• Appearance  Skin Condition

• Body build  Body hair distribution
 Anaemia  Temperature
• Oedema  Dehydration
• Jaundice  Thyroid Gland
• Pulse  JVP
• BP  Lymph node
• Heart
• Lung
• Breasts

15. Per- Abdominal Examination

1. Inspection:
 Shape of the abdomen:
 Umbilicus:
 Striae gravidarum:
 Linea nigra:
 Any scar mark:

2. Palpation:
 Symphysio-fundal height (SFH)
 Fundal grip
 Abdominal grip / lateral grip
 1st pelvic grip
 2nd pelvic grip
 Foetal movement

3. Percussion
 4. Auscultation:

16. Pelvic Examination

 Inspection of the valve , vagina, perineum

 Per- speculum examination
 Bimanual examination

17. Salient features

18. Clinical Diagnosis :

19. Investigation

20. Treatment