Obstetrics and Gynecology/Obstetrical Hx (OSCE)

Obstetrical History - Pregnancy Checkup or Complication During Pregancny

Intro

introduce yourself

ID

check: name, age, occupation
check: marital status

CC

use this to direct further questioning
ask about: supportive partner, planned pregnancy, first pregnancy

Hx

HPI/Current Obstetric Hx

Menstrual Hx

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

(last, frequency, abnormal)
EDC Calculation (LMP + 7d -3mos + 1yr)

Contraceptive Hx

Types, duration, date last use, compliance, future conception (may affect dates; progesterone/IUDS affect molar)

Current Pregnancy Hx

Bleeding, discharge, vomiting, fever
Contractions, fetal movements
Smoking, drinking, drug use

Nutrition

folate, vitamin D, caloric intake, iron, calcium

Ix

Prenatal testing – MSS + NT U/S + fetal anatomy – defects?, dating?
HIV
others: thyroid, genetics, glucose tolerance test - outcome?

MAADS

Meds, Allergies, Alcohol, Drugs, Smoking (esp during pregnancy)
~~Immunizations (?unecessary?)~~

Previous Pregnancy Hx

GTPALM
- 1. 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

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

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

Family support, adjustment, abuse

FIFE + Discussion topics

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