GUIDE IN ASKING QUESTIONS IN OB HISTORY TAKING o Place of delivery

AND PE
o Complications
HISTORY TAKING • Prenatal
1. Introduce self to patient. o Complete 4 visits?
2. Reassure confidentiality. o Tetanus Toxoid shots?
3. Demographics: o Iron & Folic acid supplements?
• Name: o Vitamin A?
• Age: • Use of contraceptives?
• Sex: 6. Past Medical History
• Address: • Previous hospitalization
• Civil Status: • Surgical procedures
• Occupation: • Allergies?
• Religion: • Immunization?
• Nationality: 7. Family History
• Education: • Hypertension
4. Chief Complaint: • Diabetes
5. OB History • Cancer
• Menarche: • Cardiac problems
• Menstrual Cycle: • Bleeding tendencies
• Duration of Menses: • Anemia
• With/without Dysmenorrhea: • Asthma
• LMP (1st day of Last Mens): 8. Personal and Social History
• Gravidity and Parity: • Work of spouse
o No. of pregnancies: • Smoking?
o No. of abortion/miscarriage: • Drinking alcoholic beverages?
o No. of livebirths: • Use of illicit drugs?
Details to ask per pregnancy 9. History of Present Illness:
o Year • Onset
o Manner of Delivery • Location
o Full term/Preterm • Duration
o Livebirth • Character
o Birth Weight • Aggravating/Alleviating factors
o Sex • Radiation
 • Time PHYSICAL EXAMINATION
• Associated symptoms • General Appearance
o Pain and pain scale • Vital Signs
o Bleeding o Temperature
✓ Pad changes o Heart Rate
✓ Fetal parts o Respiratory Rate
o Amenorrhea o Blood Pressure
o Vomiting/Nausea o O2 Saturation
o Quickening o Weight
o Breast changes o Height
o Frequent urination • Integumentary (checked simultaneously with
o Fatigue other systems)
o Skin color changes • HEENT
(face/abdomen) • Chest and Lungs
o Ruptured BOW • Cardiac
• Treatment done at home • Abdomen
10. Review of Systems o Fundic Height
• General (Weight loss/gain, Fatigue) o Leopold’s maneuver
• HEENT (Headache, Blurred vision, ▪ Fundal Grip
discharges, Singaw, enlarged lymph ▪ Umbilical Grip
nodes, bukol sa leeg) ✓ FHT
• Chest and Lungs (DOB, cough, colds) ▪ Pawlik’s Grip
• Cardiac (palpitations) ▪ Pelvic Grip
• Abdomen (Bowel changes, appetite, • Genitourinary
difficulty swallowing, Bukol bukol sa o Internal Examination
tiyan) • Extremities
• Genitourinary (Painful urination, lesions) o Temperature
• Extremities (Numbness, pain) o Capillary refill time
o Edema
REPORTING FORMAT IN OBSTETRICS
1. Chief Complaint
2. Past Medical History
3. Obstetric History
4. Family History
5. Personal and Social History
6. History of Present Illness
7. Review of Systems
8. Physical Examination
9. Initial Impression