Focused Obsteric History

If your patients condition or time prohibits a detailed obstetric history, and the current pregnancy has been confirmed, just ask these key questions. They focus on significant past pregnancy events, current pregnancy status, identification of risk factors, and health promotion activities. The patients response will help to direct your assessment.
How

many times have you been pregnant? What were the outcomes of these pregnancies? Did you experience any problems during these pregnancies? When was your LMP? Was this a normal period? When is this baby due? How was your due date determined? Since you became pregnant this time, have you: Had any x-rays? (If yes, when and why?) Been exposed to any viral illnesses, such as German measles (rubella)? (If yes, when?) Experienced any other childhood illnesses? (If yes, describe.) Had a fever? (If yes, when, and how high was your temperature?) Have you used any medications: prescribed, OTC, home remedies/herbal preparations, vitamin or mineral supplements? Have you had any bleeding or leakage of fluid from your vagina? When? Have you had any prenatal care? If yes, where and when? Do you have any medical conditions (HTN, diabetes, etc.)? How much weight have you gained so far during this pregnancy?

Biographical data: 24 years old, married, first pregnancy. College graduate, full-time social worker. Born and reared in the United States, Hispanic descent, Catholic religion. Health insurance through own and husbands work plan. Referral: Routine prenatal care. Source: Self, seems reliable. Current health status and presenting symptoms: Fatigue. Nausea and vomiting for 3 weeks. Breast enlargement, tingling, and tenderness. Urinary frequency. Amenorrhea. Past health history: Usual childhood illnesses. No surgeries, hospitalizations, or allergies. Immunizations current. Takes one multivitamin with iron daily; no other medications. Physical examinations yearly since age 18; normal Pap smears. Used oral contraceptives for 5 years without problems; discontinued them 8 months ago to

attempt pregnancy. No previous pregnancies. Family history: Grandmother, age 64, takes medication to control high BP. All other relatives alive and well; two older sisters married with children and experienced no complications during pregnancies; one younger sister is single. Review of systems: General Health Survey: Very tired for past couple of months, needs to take a nap every day when she gets home from work. Body weight 125 lb, on the low end of her normal reported range of 126 to 128 lb.Has lost 2 lb since becoming pregnant. Integumentary: Noticed nipples getting darker and line on abdomen. Hair very oily. HEENT: No changes in head/neck. Has nasal stuffiness but no colds, allergies, or flu.Gums bleed with brushing; last dental exam 6 months ago. No eye changes. Respiratory: No changes. Cardiovascular: No history of MVP, palpitations, or edema. Breasts: Enlargement, tenderness, and tingling sensation. Gastrointestinal: Nausea and vomiting in the morning, usually subsides by noon; says certain foods just turn my stomach; reports constipation. Genitourinary: Reports frequency of urination, no burning. Reproductive: LMP 4/10/06. Musculoskeletal: No changes. Neurological: Occasional lightheadedness; no history of depression; excited at possibility of being pregnant. Endocrine: No history of gestational diabetes; reports heat intolerance. Immunologic/Hematologic: No history of anemia. Psychosocial profile: Patient is proactive regarding healthcare. Has yearly physical examination and Pap smear. Performs monthly BSE. Believes people are responsible for maintaining their own health.

 Typical day consists of arising at 6:30 A.M. and eating breakfast with husband. (Lately unable to enjoy usual breakfast of cold cereal and juice because of nausea.) Drives 4 miles to office 5 days a week and works from 8 A.M. to 5 P.M. at desk part of time and interviews patients in a clinic located on the ground floor of her office building for rest of time. Loves her work. Evenings she and husband prepare and eat supper, clean up dishes, take a walk in the neighborhood, then relax by watching television, playing cards, or reading. Patient showers and goes to bed around 10 P.M. Usually eats a healthy diet, but lately has been skipping breakfast because of nausea.As day progresses, is gradually able to eat bland food, such as baked chicken, potatoes, and steamed vegetables. Walks daily for 45 minutes with husband. Has no pets. Recreation includes daily walk with husband, dinner at restaurant or movie once a week, family get-togethers.Hobbies include reading and needlework. Sleeps around 81/2 hours normally, but lately gets very sleepy at work, especially in midafternoon. Combats sleepiness with a walk outside her office and an afternoon snack of fruit and yogurt or crackers.Takes a short nap after work.No problems falling asleep. Does not smoke, use drugs, or drink alcoholic beverages. No chemical exposure at work. Lives in a one-story, two-bedroom single-family home in suburbs; has hot water, heating, and air conditioning; negative for radon gas.Will convert guest room into babys room.No recent travel outside local community. Catholic religion, Hispanic nationality (third generation).No religious or cultural influences that affect healthcare, pregnancy, or delivery. Supportive, caring husband (nonsmoker) who is computer analyst for national company; married 5 years; attempted pregnancy for 6 months. Mother,mother-in-law, and three sisters live in same community and will assist with infant

care. Patient plans to breastfeed and stay at home for 6 weeks after birth and then return to job. Copes with stress by walking, talking with husband and family members, doing needlework.