Table of Contents
Introduction
- Wash hands
- Introduce self
- Ask Patient’s name, DOB and what they like to be called
- Explain and obtain consent
Presenting complaint
- Determine symptoms which brought patient in
History of presenting complaint
- Explore every symptom
- Timeframes
- Symptom-specific questions (see exploring symptoms)
- Relevant systems reviews (see systems review)
- General
- Gynaecological (The 4 P’s)
- Gastrointestinal (∆∆ IBS, malignancy, appendicitis, diverticulitis etc.)
- Urological (∆∆ UTI, incontinence etc.)
The 4 P’s
PV bleeding
PV discharge
Pain
Pregnancy
- Fetal movements (if over 16-20 weeks)
- Contractions/tightening
- PV blood loss
- Pre-eclampsia symptoms (headache, visual disturbance, epigastric pain, oedema)
Current pregnancy
- 1st day of last menstrual period (gestation = time since then) and when +ve pregnancy test
- Scans so far (intra-uterine? Any abnormalities?)
- Investigations (especially Rhesus group, Down’s syndrome risk, mid-trimester scan)
- Problems/admissions this pregnancy
- Vomiting/hydration
Obstetric history – GMC
- Gravida and para
- Gravida/gravidity = pregnancies
- Para/parity = birth of fetuses over 24 weeks, regardless if born alive or not
- Miscarriages, ectopic pregnancies and terminations
- Stage
- Treatment
- Complications
- Children (living)
- Number
- Ages
- Birthweights
- Type of deliveries
- Previous problems during pregnancy/delivery
Rest of history as normal
- PMHx
- DHx
- FHx
- SHx including drugs, alcohol and smoking
