Dr w.

banna
HISTORY TAKING AND SHEET.
1.Personal hist:

 Sabah neyazy mostafa, 27 years old, married

for 2 years primigravida, living in dokki,with
no special habits of medical importance.

 Her husband alaa kareem nabil,35 years old

driver he smokes 3 packs of cigarettes
everyday.
Martial status:

 Married, widow, divorced or single

 If married :
 Gravidity and parity
 Gravida……,para…..
 How many living & males or females . And the
youngest is ……. Years old .
Husband??????????????

 Is that important ?
 Very important and you must comment
about it . Sometimes certain occupations may
decrease the sperm count due to varicocele,.
In obs sheet

 (…)gravida and not gravida(…..)

 What 4th gravida means ?

 Means she has been pregnant four times but
not necessarily she delivered 4 babies .
 By patient own language ( they told me I’m
pregnant and I did pregnancy test and was
positive .
Habits

 Smoking leads to preterm labor , pre

eclampsia and I U G R
 Alcohol ( leads to fetal alcohol syndrome )
 Cocaine leads to early abortion and preterm
labour.
 Now specific points regarding each medical
disorder with pregnancy that you must ask
about it .
 And actually you are going to ask about the
risk factor which can be accompanied by the
disease
IN HYPERTENSION

 Gravidity and parity is vip cuz pih is a disease

of ,,,,,,,,,,,,,,, and multipara with pih
means,,,,,,,,,,,,,,,,, or diabetic effect .

 (fill in the space above )

In diabetics

 Age above 35
 Grand multipara or even multipara
Complaint ::

 What is the most distressing complaint and

what brought her to the hospital.
 Byyyyyyyyyyyyyyyyyyyyyyy Her own words.
Example

 She is pregnant in 8th month coming for

antenatal care.
Present history :

 Complaint onset . Course. duration

 Then
 1 analysis of comp
 2analysis of symp
 3 analysis of ttt.
1:

 She is pregnant 34 weeks as 1st day of lmp

was 20/8 /2007 her edd was 27/5/2002

 Ya3ny 1st thing to calculate the gestational

age .
2: review of 3 trimesters

 1st : vomiting , bleeding

 2nd : ( perception)
 When and how many now the fetal kicks
 3rd warning signs:
 Headache, blurring , excessive vomiting,
epigastric pain, decreased fks , LL oedema ,
 V.bleeding , rom,
 Then specific for each ………
For hypertension:

 Headache : onset course duration

 Severe vomiting ,blurring, epigastric, rt
hypochondrial pain, ll oedema
 Protienuria
 Hist of renal dis.
 Covulsions
 The corner stone here is the hist. of hyper .
Before preg.
For diabetes :

 1 when she knows that she is diabetic

 In this pregnancy or previous
 Treatment in between.
 2 sypmt. Of diabetes
 Polyuria , polydipsia , excessive thrist .
 3 management
 Are you taking drugs or just diet control .
 Insulin and its type , dose by units and shots
 when.
For DM:

 Last measurement of glucose .

 Was it fasting or postprandial and was it good
 Urine analysis and for glucose and acetone
 Also cover the question of hypertension
How to ask about macrosomia
and polyhydramnos
 Fudal level.
Associated symp of dm

 Vaginal dis, monilial

 Amount color odor
 Itching
 Treatment .
4. Admission and ivest.and
ttt
 When and why and what they did for you.
 Cbc, lft, kft and the result.
 Urine ana.
 Drugs (what and dose)
 Fetus assessment
 Ultrasound , reviled ?????
 Ctg , fks
Points that you must not to
forget it.
 Future management
 And mode of delivery
Obs history.
 Wish you all the best of luck my future
colleagues .

Dr wael el banna