Obstetrics post-operative history taking format for medicos

1. Piyush Ranjan Sahoo

2. • Chief Complaints
 pain/fever/wound complication/urinary retention etc.
headache, vomiting
 if not having any, tell-
 __yr female P (no. of child) on __ day of puerperium
with no specific complain.

3. History of Present Illness
 -Describe pain—onset, location, duration, character,
association, aggravating n relieving factors, radiation,
with reln to time.
 -Describe fever (puerperal pyrexia)—type, asso. with
any other factor.
 -Wound complication- Infection, stitch problem,
pain at wound site, any bleeding/discharge, or
swelling.
 -Urinary retention- (look for catheterisation n
accordingly present history) frequency of urination,
urinary output.

4. Hist. of past illness
 medical hist.
 surgical hist.(obs/gynaec/general)

5. Family History
 Mention as routine
 If Any relevant finding, mention.

6. Menstrual history
 Menarche
 prev. cycle
 LMP
 GA on the day of surgery, EDD.
 Cycle- duration of flow, amount of flow, association
(e.g. pain), regular or not.

7. Personal history
 Occupation
 Education
 SES
 wt gain
 Diet
 Addictions
 B/B habit

8. Obs hist.-
No. of
pregnancy
Yr
of
pregnancy
Duration of
Pregnancy
(complication
s
if any)
Duration
of
labour
Mode
Of
delivery
Nature
Of
puerperium

9. Baby
Sex weight Health
of
the child
If dead,
cause of
Death.

11. Antenatal events-
1st trimester events-
 Morning sickness, fever (with rashes or not), vomiting,
bleeding PV, Abd pain (may be due to UTI/ectopic
pregnancy)
 Medication hist.- Folic acid(neural tube development)
 USG done or not( for location of pregnancy & uterine
anomaly)
 ANC (booked case or not).
 Visits-

12. Continued…
2nd trimester events-
 Abd pain, bleeding PV, quickening, PIH(blurring of
vision, pedal oedema), Glucose challenge test ( to
know GDM).
 Medication hist.- Fe(not in 1st trimester, causes
vomiting n GI prob.), Ca+2 (to prevent osteoporosis),
TT( 1st dose at 16 wks, 2nd dose after 4-6wks).
 USG done or not. – ANC

13. Continued…
3rd trimester events-
 Abd pain, PIH, GDM, Bleeding PV.
 Med history-Fe, Calcium ..contd or not.
 USG –ANC.

14. Labour events-
 Pain- duration
 Bleeding
 Leaking

15. Puerperal events-
 Bleeding (for PPH)
 Any complications or illness

16. Fetal outcome-
 Wt-
 Crying, feeding, colour, CRT
 Any abnormality
 Immunization

17. General examn-
 Ht n wt, built, gait, pulse, BP, RR, temp., PICKLE
Breast examn-
 Inspection- skin, nipple n areola, engorged veins, any
discharge
 Palpation-lax, tender or not, any mass
Thyroid examn- (optional)
Abdominal examn- ( same as medicine)
***No percussion is to be done.

18. Thank u