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Obstetrics post op history taking

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Obstetrics post-operative history taking format for medicos

Publié dans : Santé & Médecine
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Obstetrics post op history taking

  1. 1. Piyush Ranjan Sahoo
  2. 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. 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. 4. Hist. of past illness  medical hist.  surgical hist.(obs/gynaec/general)
  5. 5. Family History  Mention as routine  If Any relevant finding, mention.
  6. 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. 7. Personal history  Occupation  Education  SES  wt gain  Diet  Addictions  B/B habit
  8. 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. 9. Baby Sex weight Health of the child If dead, cause of Death.
  10. 10. 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-
  11. 11. 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
  12. 12. Continued… 3rd trimester events-  Abd pain, PIH, GDM, Bleeding PV.  Med history-Fe, Calcium ..contd or not.  USG –ANC.
  13. 13. Labour events-  Pain- duration  Bleeding  Leaking
  14. 14. Puerperal events-  Bleeding (for PPH)  Any complications or illness
  15. 15. Fetal outcome-  Wt-  Crying, feeding, colour, CRT  Any abnormality  Immunization
  16. 16. 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.
  17. 17. Thank u