Obstetrics and Gynecology/Obstetrical Hx (OSCE)

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Obstetrical History - Pregnancy Checkup or Complication During Pregancny

Intro[edit | edit source]

  • introduce yourself

ID[edit | edit source]

  • check: name, age, occupation
  • check: marital status

CC[edit | edit source]

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

Hx[edit | edit source]

HPI/Current Obstetric Hx[edit | edit source]

Menstrual Hx[edit | edit source]

  • 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 | edit source]

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

Contraceptive Hx[edit | edit source]

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

Current Pregnancy Hx[edit | edit source]

  • Bleeding, discharge, vomiting, fever
  • Contractions, fetal movements
  • Smoking, drinking, drug use
Nutrition[edit | edit source]
  • folate, vitamin D, caloric intake, iron, calcium
Ix[edit | edit source]
  • Prenatal testing – MSS + NT U/S + fetal anatomy – defects?, dating?
  • HIV
  • others: thyroid, genetics, glucose tolerance test - outcome?
MAADS[edit | edit source]
  • Meds, Allergies, Alcohol, Drugs, Smoking (esp during pregnancy)
  • Immunizations (?unecessary?)

Previous Pregnancy Hx[edit | edit source]

  • 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[edit | edit source]

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 | edit source]

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 | edit source]

  • Family support, adjustment, abuse

FIFE + Discussion topics[edit | edit source]

  • 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

ROS (if time)[edit | edit source]

Appropriately End Interview[edit | edit source]

Other OSCE Modules[edit | edit source]