OBGYN HISTORY TAKING AND WRITE UP Introduction Everyone aspires to be a doctor for the express purpose of treating patient

and preventing illness. The only way this can be done is to make a diagnosis first or in other words, to find out the cause of the patients problem. The main tools for achieving this are a proper clinical history and examination. Thus, obtaining an accurate history is the critical first step in determining the aetiology of a patients problem. If done properly, a diagnosis can be made in a large percentage of patients based just on the history alone. The Obstetric History serves 2 purposes, namely, to provide a synopsis of the patients background risk and an account of the progress of the pregnancy. Also, a carefully taken history provides a clinical guide for the physical examination that follows. Clinical history should be taken and presented in a logical sequence. Of necessity, the initial sequence must include the chief complaint, history of present illness (HOPI), history of current pregnancy (HOCP) and history of past pregnancy (HOPP) in that order, although HOPI and HOCP may be combined if required. Other histories such as medical, surgical, family, social, drug and menstrual or gynae history then follow, but these may be arranged in order of relevance to the HOPI or HOCP. Chief Complaint The chief complaint is the main reason a patient seeks medical help. Although the patient may be subsequently referred to a hospital or other centre, it is important to find out why she first sought help. It is usually written and presented in a short phrase, for example, abdominal pain or vaginal bleeding. And since the patient describes the problem in her own words, it is customary that the complaint be recorded as such, rather than in medical terminology. Description of the chief complaint is completed by proscribing the duration of the problem with reference to the time of admission, for example, per Vaginal bleeding for 3 days prior to admission. Sometimes, the patient gives more than 1 chief complaint. In this case, each complaint is to be mentioned separately and completely. History of Current Illness (HOCI) Having determined the main reason for the patient seeking help, the next step is to elaborate the chief complaint in detail. As such, relevant and pertinent questions need to be asked keeping in mind all the common possible diagnoses that can cause the chief complaint. A proper and good HOCI consists of 4 components, as follows below. Any HOCI is begun with a description of what is called the demographic information. This is a summary of the details and includes the patients name, age, gravidity and parity, and the dates of the last menstrual period and expected due dates. At this point, it is good to recall that gravidity refers to the number of pregnancies inclusive of the current pregnancy, regardless of the outcome of each pregnancy. Parity is defined as the number of births (live and stillborn) that occur after 24 weeks of gestation. Up to this point, the history-taking process is relatively straightforward. In order to proceed further, the next step a student should take is to combine the foregoing information (chief complaint and demographic information) and mentally come up with a shortlist of differential diagnoses. For example, the causes of vaginal bleeding in late pregnancy are placenta abruption, placenta praevia,

cervico-vaginal infection and trauma. This step is essential in determining the course of questions to be asked. The next component may be called the primary history and describes the onset, course, severity and duration of the chief complaint. This portion elaborates on the main complaint and it deals with the chronology and the characteristics of the chief complaint. Questions such as the anatomic location, quality, quantity or severity, timing, setting in which the symptoms occur, aggravating and relieving factors need to be asked. If there is more than 1 chief complaint, repeat this series of questions for each complaint. In this case, each symptom has to be taken individually and followed through fully before moving on to the next symptom. Not all questions may be relevant for a symptom. For example, a location cannot be determined for difficulty in breathing. The next step is to expand on the primary history and record the associated symptoms. This may be thought of as a general review of systems and requires more experience on the part of the interviewer than the recording of the primary history. Information gathered here serves to support the diagnosis as well as to gauge the severity of the disorder. As examples, for a complaint of abdominal pain, associated symptoms would include the presence or absence of nausea and vomiting, and for vaginal bleeding, any per vaginal discharge, pruritis or smell is deemed relevant. And finally, the HOCI is completed by asking for any symptoms of the complications of the disorder. Again, this would help to confirm the diagnosis and assess the severity of the problem, thus establishing an idea of the management that is to follow. As a guide, if a patient has complained of symptoms of urinary tract infection (UTI) such as dysuria and increased frequency of micturition, it is customary to inquire about loin to groin pain, backache and fever which might suggest ascending infection complicating the UTI. History of Current Pregnancy (HOCP) A good HOCP should always be concise and presented in a chronological manner beginning with the first trimester and on till the third. Right at the beginning, it should be stated if the patients menstrual periods were regular and if she is certain of the date of her last menstrual period (LMP). These facts would serve to confirm gestation. If possible, it must be determined how the pregnancy was confirmed. Most women suspect they are pregnant when they miss their menstrual period and confirm it with a urine pregnanediol test (UPT). This may not be accurate and prone to false positives or negatives and it is much more comforting if an ultrasound scan (u/s) has been done. Another important confirmation of the dates is the time of onset of early pregnancy nausea, vomiting and other symptoms which typically appear around the 7th week of gestation. Any earlier or later appearance, or absence, of such symptoms must be documented and might suggest an abnormal pregnancy such as a miscarriage or molar pregnancy. Later on in pregnancy, the time of quickening affords further confirmation. Primigravidae experience this around 20-22 weeks whereas multiparas have this sensation earlier from between 16-18 weeks of gestation. Routine tests are performed during the time of booking and it would be helpful to know the results. If these are normal, it is sufficient to just say so. However, of particular importance are the haemoglobin level (Hb) and the early blood pressure (BP) reading, which should be stated if known. ABO and Rhesus blood grouping are also important with specific significance for Rhesus negative patients. Although it is recommended that all women undergo early pregnancy u/s scanning, this is not often the case. Such a scan would help document the number of fetuses, the viability (presence of fetal heart movement) and the measurement of the crown-rump length (CRL) to confirm the

gestational age. This is the bare minimum information that should be gleaned from the patient although u/s scanning can disclose more. The patient would subsequently undergo numerous antenatal check-ups. During case presentation, it is sufficient to say that the antenatal check-ups were normal if so. Second trimester u/s scanning is mainly done to assess for fetal anomalies and this point should be specifically mentioned even if not done. Nowadays, it is becoming routine to screen all pregnancies for diabetes mellitus (DM). In the past, this was done based on the presence of risk factors, but it was found that even those women without any such risks were prone to develop DM and consequently being missed out until too late. Screening is now done at first booking and may be repeated at 24-28 weeks of gestation if suspicion of DM arises or persists. Most places carry out the 75g oral glucose tolerance test (OGTT) but a glycosylated Hb (HbA1c) can also be used. Therefore, a student should document if DM screening was done, at what gestation and the normality of the results. Even though screening is becoming routine now, efforts must be made to list the risk factors that a patient might have. If the results of the test are abnormal, the subsequent action taken to manage this disorder has to be mentioned. This can be regular serial sugar monitoring, diet modification, oral or insulin therapy. Fetal growth is an important indicator of diabetic control and any development of macrosomia and polyhydramnios is important. An important point in the management of medical disorders in pregnancy is the prepregnancy presence of the disorder. Active questioning must be carried out to determine this status because of the important implications on the classification of the condition, the risks involved and ultimately, the management of the pregnancy. Patients are becoming increasingly aware of their disease status but it is up to the interviewer to document this. DM and hypertension are the most common medical disorders encountered but other conditions that spring to mind are epilepsy, thalassemia, anaemia and heart disease. History of Past Pregnancies This section details the events and outcomes in the patients past pregnancies, if any. These may have important implications as well as give clues on the current problem the patient is facing. It is enough to summarize significant points that occur during the antepartum, intrapartum and postpartum periods rather than listing them out in point form. Needless to say, any abortions and ectopic pregnancies and their outcomes have to be mentioned. Apart from the occurrence of the current complaint, significant consideration should be given to conditions such as anaemia, DM, hypertension and PPH in the past pregnancies. The mode of deliveries, birth weights of the babies as well as breastfeeding and its duration provide insight on the physical and mental status of the mother. The practice of contraception, any side effects and the reason for stopping might reflect on the well-being of the current pregnancy. Other histories The next set of histories is usually presented as separate individual sections and most students tend to present them as such. However, there should be flexibility in the order of listing them depending on their importance with regards to the current illness. For example, if the patient has been referred for management of DM, a family, dietary and social history should take precedence over, say, menstrual history. Similarly, if the problem is one of wrong dates, then a detailed menstrual history becomes very important. In this case, and in others, it is always

important to determine at the outset the regularity of the patients periods and any suggestions of illness such as dysmenorrhoea and pelvic pain. Past history of infertility is significant as such patients are prone to a higher risk of pregnancy complications, especially during the first trimester. We continue with the past medical and surgical history. The patient should be questioned on any known pre-existing illness, how it was diagnosed and the current status. Any indications for surgery and the type of surgery performed are also important points. This data is necessary as the patients current complaint might be a part of past illness. Some medical conditions may also have an impact on the course of the pregnancy, for example hypothyroidism. On the other hand, the pregnancy itself may have an impact on the medical condition, as in heart disease. It is customary to include past trauma and accidents in this section. One should also not forget minor procedures such as endoscopies, biopsies, dental procedures, childhood diseases and even questions on vaccinations if relevant. To illustrate these points, here are a couple of examples. In the case of suspected fetal anomaly, past history of Rubella vaccination is important. Dental procedures such as tooth extraction and cavity filling may be a source of infective endocarditis in patients with valvular heart disease. Following on from the above histories, it is natural to want to know if the patient is on any medications. This drug history can be of significant relevance to the course of the pregnancy. Although most drugs are quite safe to be taken during pregnancy, some are not, and can be quite teratogenic. An epileptic patient on sodium valproate is prone to congenital anomaly and this history would be relevant in a patient referred for a uterus that is smaller than dates. Medications can also be affected by the increased amounts of proteins produced by the pregnant women. This leads to increased drug-protein binding, thus leading to decreased bioavailability and efficacy of the drug as can be seen in the case of replacement thyroid hormone for hypothyroidism. Some drugs have side effects that may be exacerbated during pregnancy such as patients on aspirin for heart disease, hypertension or recurrent abortion who may experience gum and other bleeding. Documentation of drugs or medication must always use the generic name, although the trade name can be put in brackets. The person who initiated the medication, the dosage, timing and duration of therapy are all important. Nowadays, it is very common for patients to be on supplements, vitamins, traditional, herbal, alternative and other similar therapy, and this should not be forgotten. There have been many instances of patients presenting with Steven-Johnson syndrome due to herbal medications. As a final check, blood transfusions and their indications should also be questioned for. Family history of illness seeks to determine the presence of any heritable or communicable disorders that may impact the pregnancy. DM springs to mind and is one of the chief disorders that need to be determined. Hypertension is the other. These questions are usually asked during pregnancy booking and the patients are mostly aware of them. If present in the family, these and other disorders may occur during pregnancy and be the cause of the current complaint. If not, it is just good to know as a means of determining and documenting the risks. Currently, communicable diseases such as dengue and avian flu seem to be more common and should be asked for specifically especially when the chief complaint is fever. Most Malaysian mothers dont usually smoke or drink alcoholic beverages, yet this is asked as a routine. A social history of smoking and drinking does not impact on pregnancy as has been shown in many foreign studies, yet students seem to be fixated on these points at the expense of other more important social histories.

Summary By the time the end of the history taking is reached, the interviewer should have a pretty good idea of the cause of the patients problem. In some cases, a diagnosis can even be made based on just the history alone and the ensuing physical examination would serve to just confirm the diagnosis. A good history does not need to be long; rather, it should be short, compact and complete. It should provide the listener with a good idea of the patients problem and the current state of the pregnancy. Hanifullah Khan bin Wahidullah Khan Associate Professor Dr O&G & Laparoscopic Surgeon & Reproductive Endocrinologist