Obstetrics and Gynecology/Obstetrical Hx (OSCE)
Obstetrical History - Pregnancy Checkup or Complication During Pregancny
Intro edit
- introduce yourself
ID edit
- check: name, age, occupation
- check: marital status
CC edit
- use this to direct further questioning
- ask about: supportive partner, planned pregnancy, first pregnancy
Hx edit
HPI/Current Obstetric Hx edit
Menstrual Hx edit
- LMP; cycle length; (for EDC calculation)
- regularity = regular vs. irregular (metrorrhagia)
- flow: normal duration, quantity vs. prolonged,heavy (>7d,tamps/day; menorrhagia)
- color (dark red vs. bright (AUB))
pain (? nonspecific?)PMS - headaches, anxiety, breast tenderness (? nonspecific?)Menarche, Menopause (? later is worse? nonspecific?)
PAPs Hx edit
- (last, frequency, abnormal)
- EDC Calculation (LMP + 7d -3mos + 1yr)
Contraceptive Hx edit
- Types, duration, date last use, compliance, future conception (may affect dates; progesterone/IUDS affect molar)
Current Pregnancy Hx edit
- Bleeding, discharge, vomiting, fever
- Contractions, fetal movements
- Smoking, drinking, drug use
Nutrition edit
- folate, vitamin D, caloric intake, iron, calcium
Ix edit
- Prenatal testing – MSS + NT U/S + fetal anatomy – defects?, dating?
- HIV
- others: thyroid, genetics, glucose tolerance test - outcome?
MAADS edit
- Meds, Allergies, Alcohol, Drugs, Smoking (esp during pregnancy)
Immunizations (?unecessary?)
Previous Pregnancy Hx edit
- GTPALM
- pregnancies, term, premature (< 37 wks), abortions, live deliveries, multiples
- Year, sex, age children, birth weight
- Labour – type (vaginal or Cesarean), complications
- Postpartum complications (depression - "baby blues", feeding)
PMHx + SxHx edit
Do you have any health problems (other than the bleeding or whatever)? Have you had any operations or illnesses? Many people have had psychological or emotional illnesses like depression. They may find it difficult to talk about. Have you had any illnesses of this kind?
- ToRCHHS – toxoplasmosis, rubella, CMV, HIV, HSV, syphilis
- Coagulopathy
- Other illnesses/surgery? - Diabetes, HTN, kidney/heart/thyroid disease
FHx edit
Are there any illnesses that run in your family? Have any of the women in your family had problems with pregnancy? Have any babies been born with a problem or developed one later?
- Heart, diabetes, hypertension, seizures
- Genetic diseases (CF), congenital abnormalities (spina bifida, cleft lip)
Multiple pregnancies (? nonspecific?)
Social Hx edit
- Family support, adjustment, abuse
FIFE + Discussion topics edit
- Feelings towards pregnancy, partner abuse?
- Ideas – what it’s going to be like, breastfeeding, prenatal classes
- Function – affect work? relationship w/ partner?
- Expectations – physician’s role, regular check-ups