This article based on clinical medicine course because that course deals with the taking of history of patients during the hospital. Each history has its format and principle by simple meaning the difference of history is depend on department of the patient based. If the patient has obstetric cases the history that will be taken will be obstetric history and mostly different from other history like internal medicine and pediatric
In order to know to understand and learning how to writing a good perfect and best history some material and thing =s you need to be with that form examples, clerkship of specific history you want to know, and also thing like clinical area attending routine and also rating scale, but the things you need to be with like clinical attendance that will help to get experience
But this content wants to share with you a really, perfect and best history taking of obstetrics history. But also, you can download this that a best example of history taking of obstetrics history. Below after ending of this history taking.
Obstetric History
Demographic data
Name: Zukra Abdu
Age:21 years
Sex: Female
Tribe: Makua
Adress: Mlundelunde
Religion: Muslim
Gravida:2
Para:1
Living:1
LNMP: Not remembered
Estimated Ga:8 weeks
DaC:22nd4 2018
Chief complain
Lower abdominal pain 1/7
Per vagina bleeding 1/7
History of presenting illness
Seen a patient came with a complain of lower abdominal pain for 1 day of gradual onset, cramping in nature with neither aggravating nor relieving factor not associated with painful urination, increased frequency of urination, loss of appetite, passage of loose stool, nausea, vomiting, constipation no fever.
Also, patient had per vaginal bleeding of gradual onset started with fresh blood increasing with time later contained clots with no foul smell not mixed with any abnormal vaginal discharge, no vaginal itching associated with dizziness and heart beat awareness not associated with difficulty in breathing, chest pain, cough, blurred vision, headache, no loss of consciousness.
Review of other system
Muscular skeletal system
No muscle pain
No joint pain
Past medical history
This is 2ndadmission
1stadmission was in 2014 due to labor
No history of BT
No any known drug/food allergy
Obstetric history
Index pregnancy
Tested urine pregnancy test was positive
Not booked for antenatal clinic
Previous pregnancy
Pre term delivery in 2014 by SVD at Mkomaindo hospital
A baby boy of 2 kg
No history of any disease during pregnancy
No history of post-partum complications
Gynecological history
Menarche at 15 years
Circle of 30 days
Period of 5 days
Changed pads 3 times in a day
Used Depo Provera stopped in 2017 due prolonged bleed
No history of dysmenorrhea
No history of STI
Family and social history
Did not get formal education
Peasant
Cohabiting
No history of inherited disease
No history of cigarette smoking and alcohol consumption
General examination
Conscious, oriented with people, time and place,
Good hair distribution, color and texture according to age and race,
No conjunctival pallor, no sclera jaundice
No eye, ear, nose discharge
No angular cheilitis, no stomatitis, no cyanosis, no oral thrush
No enlarged palpable lymph nodes
No palmar pallor, No finger clubbing, no koilonychia, capillary refill is < 3 sec
No lower limb oedema
Vital signs
BP 110/60 mmHg Normal
PR 75 b/min Normal
RR 20 c/min Normal
Temperature 36.6 
C Normal
Systemic examination
Per abdomen
Inspection
Normal abdominal contour
No surgical scar
No traditional marks
Moves with respiration
There is linear nigra
Palpation
Superficial palpation
No tenderness
No superficial mass
Deep palpation
No tenderness
No organomegaly
Percussion
Tympanic sound heard
Auscultation
Bowel sound heard
Pelvic examination
Per vaginal inspection
No ulceration
No swelling
There some blood clots
Digital vaginal examination
Cervix was thin and soft, dilated 4 cm, some clots seen
Cardiovascular system
Inspection
No distended jugular vein
No pericardial bulging
No pericardial hyperreactivity
Palpation
Pulse rate was strong and regular
Radial and femoral pulse were synchronized
No pericardial tenderness
Apex beat was located at 5th inter costal space
Auscultation
S1 and S2 heard with no added sound
Respiratory system
Inspection
Chest is bilateral symmetrical
Moves with respiration
No surgical mark
No traditional mark
Palpation
Trachea was centrally located
No chest tenderness
Normal tactile vocal fremitus
Percussion
Resonance sound heard
Auscultation
Vesicular sound heard
Central nervous system
Higher center
Conscious, oriented with people time and place
Short- and long-term memory was intact
Cranial nerves examination
All cranial nerves except number X were tested and intact
Motor system examination
Normal muscle bulk
Normal muscle tone
Muscle power 5/5
Summary
Zukra Abdu 21 years from Mlundelunde, G2 P1 L1 but did not remember her LNMP, estimated gestation age 8 weeks. Came with complain of lower abdominal pain and per vaginal bleeding for 1 day blood contained clots with no foul smell associated with dizziness and heart beat awareness, no fever. Not pale, cervix was soft and thin dilated 4 cm. Vital sign wasBP 110/60 mmHg Normal, PR 75 b/min Normal, RR 20 c/min Normal, Temperature 36.6 C Normal.
Provisional diagnosis
Incomplete abortion
Differential diagnosis
Inevitable abortion
Investigations
Hemoglobin level estimation, blood grouping and cross matching
Pelvic ultrasound
Treatment
Intravenous fluid Ringer’s lactate 1 L
Capsule Amoxicillin 500mg 8 hourly 5/7
Tablets Metronidazole 400mg 8 hourly 5/7
Ferrous-sulphate Folic acid 205mg od 6/52
Manual vacuum aspiration
Post abortion care
Teach about the complications of abortion
Counsel and offer family planning options
Counsel for HIV
Discus about future sex fertility
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