Question

Given the following situation below, make an OB history. It must be written in paragraph form, using the format presented in the module. Place you answer here in this platform. Do not attach a file but answer on the space provided below.

Situation:

Cristina is a 29 year-old woman, 16 weeks pregnant, who comes for a first prenatal visit.She is concerned because she didn’t realize she was pregnant until a week ago. Because of this, she has been actively dieting (two diet drinks plus one meal of mainly vegetables daily) plus lifting weights at a health club. She wants her urine tested because “ I have to go all the time”. She does not want any blood work done because she doesn’t have any insurance. She hasn’t had a pelvic examination since she was in high school, when she had a vaginal infection.

Cristina is single, lives by herself in one-bedroom apartment. She works at a laundry and her boyfriend is a roofing salesman, out of town 4 days a week.

She had her menarche at age 11; menstrual cycle every 29 days, 6 days duration with moderate flow and mild cramps. Past history positive for sinusitis and appendectomy at age 12 years. Smokes about ½ pack of cigarettes per day (“more when I’m stressed at work”); denies alcohol use.

She weighs 195 pounds and stands 5 feet 5 inches; breast full and slightly tender.

Pelvic examination by nurse-midwife:

            Cervical os round, clean, and slightly soft; uterus enlarged and soft;

            + chadwicks; + hegar’s sign; + Goodell’s sign; uterine height palpable at 3 fingers over symphysis pubis. Fetal heart rate via Doppler at 152 beats per minute.

Remainder of physical examination within normal limits. Serum HCG and ultrasound positive for pregnancy.

Answer 1

Here ,with this question,they needs to know whether you know to categorise the given information into different headings and present the case systematically.
Usually in presenting an OB case ,we should have a history, general examination and system examination where,we divide history into subheadings such as
1)Biodata
2)presenting complaints
3)history of present illness
4)past history
5)menstrual history
6)treatment history
7)personal history
8)family history
9)socio economic status

Iam giving you some information in bracket in between which are the explanation of the abbreviations.

So ,arranging the given information under the following headings ,we would get

Presenting the case of Cristina ,a 29 year-old lady,who is G1POLO (obstetric score) and whose LMP (last menstrual period ) was on...and EDC (Expected date if confinement) on ......now 16 weeks of gestation.

Presenting complaints

Increased frequency and amount of urination -....Weeks/months

History of present illness
The patient was in her usual state of life till 2 weeks before ,then she developed increased frequency and amount of urination .(Describe about the symptoms then,how often she had to go ,was it associated with pain ,hematuria etc or was it associated with increased thirst and hungriness ) she then did the urine pregnancy test and incidentally found out that she was pregnant .She was concerned about this pregnancy as she was in a diet and workout plan for the last ...month and thus presented to the OPD (out patient)

(In OB case,then we have to say about history kn each trimester ,since the patient is in 4th month ie the 2nd trimester,we will have to day about the T1 and T2)

First trimester
Pregnancy was detected in the 3rd month incidentally by the urine pregnancy test.It was an unplanned pregnancy.
There is no history of nausea vomiting ,bleeding per vaginum,radiation exposure ,fever with rash

2nd trimester
Quickening felt at (movement of the bay)....Weeks
She developed increased urine output and increased thirst from 4th month of gestation.
No antenatal checkups done till now .
No history of bleeding pv/leaking pv

Past history
There is a history of vaginal infection 10 years before when she was at high school,she did take some medication and the illness subsided.There is no history of any pelvic examination done till now.
She had sinusitis and appendectomy at age of 12 years.

Menstrual history
She had her menarche at age 11; menstrual cycle every 29 days, 6 days duration with moderate flow and mild cramps.

Personal history

She Smokes about ½ pack of cigarettes per day (“more when she is stressed at work”); and denies alcohol use.

she has been actively dieting (two diet drinks plus one meal of mainly vegetables daily) plus lifting weights at a health club.

Family history
Cristina is single, lives by herself.
her boyfriend is a roofing salesman.
There is no history of any significant illness in her family ,there is no history of any repeated abortions or twinning in the family.

Socio economic status

She belongs to a low socio economic statud.She is single and lives by herself in one-bedroom apartment. She works at a laundry and , her boyfriend is a roofing salesman, out of town 4 days a week.
She doesn’t have any insurance, because of which she says she doesn't need any blood work done.

Examination

General examination
She is conscious and oriented.No pallor icterus cyanosis clubbing lymphadenopathy and thyroid enlargement.She weighs 195 pounds and stands 5 feet 5 inches; breast full and slightly tender.

Other systems
Within normal limits

Per abdomen examination
.....(.Have to write the examination findings)

Pelvic examination by nurse-midwife:

Cervical os round, clean, and slightly soft; uterus enlarged and soft;

+ chadwicks; + hegar’s sign; + Goodell’s sign; uterine height palpable at 3 fingers over symphysis pubis. Fetal heart rate via Doppler at 152 beats per minute.

Other investigation

Serum HCG and ultrasound positive for pregnancy.

Diagnosis.
...(have to write)