History and Physical Examination Pregnancy Paper

History and Physical Examination Pregnancy Paper

History and Physical Examination Pregnancy Sample

Pregnancy is characterized by numerous physiological changes and many risks may be encountered. For desirable outcomes, all risks should be handled promptly and history-taking provides an avenue to identify them (Park et al., 2020). The purpose of this paper is to elaborate on the obstetric history and physical examination.

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History Taking in Pregnancy

The practitioner should introduce themselves at the beginning of history. Demographic information including patient name, age, and residence should be assessed. These can have specific health implications such as elderly primigravida or even residence in disease-endemic areas. Additionally, parity, gestational age, and estimated date of delivery follow. The chief complaints can then be assessed and may include backaches, palpitations, and Headaches. The practitioner aims to determine the nature of the problem, the onset, the duration, symptoms, and associated factors. The patient can then be probed on the history of the current pregnancy to include complications experienced, fetal movements, antenatal clinic visits, and any interventions done.

This enables addressing potential risks and provides avenues for health promotion for a desirable pregnancy outcome. The past obstetric history can then be assessed. This includes the total number of pregnancies, any problems experienced, and their outcomes. This may enable the identification of recurrent pregnancy risks such as hypertensive disorders in pregnancy. Practitioners can then probe into past medical and surgical history. These can include previous treatment for urinary tract infections or surgical procedures such as appendicectomy. The drug and allergy history to identify all current medications and drugs the patient is allergic to. Additionally, the gynecological history of the patients can be explored (Smith & Netter, 2018). Social and family history is important to identify lifestyle issues such as any drug abuse and inherited disorders. To conclude, a review of systems can be performed to ensure all aspects are covered then a summary of the findings can be drawn.

Physical Examination of The Patient

A chaperone should always be present and ethical issues should be upheld. Informed consent has to be given so that patients have an idea of the extent of the examination. The examination can begin with a general exam. The vital signs can be determined and obvious patient anomalies observed. Aspects of the general exam also include ruling out central and peripheral cyanosis, edema, conjunctival and buccal pallor, jaundice, lymphadenopathy, and dehydration (Decherney et al., 2019). An obstetric exam can then be performed and the aims of this are to determine the fundal height, the presenting part, fundal contents, the fetal lie, engagement, and fetal heart rate. A systemic exam can then be performed. This includes a CNS, respiratory, cardiovascular, abdominal, and genitourinary exam. A mental status exam can also be performed. A summary of the examination findings should then be drawn.

Conclusion

Pregnancy can be viewed as a stressful situation for a patient due to the numerous physiological changes. Elaborative history and physical examination are key to identifying risks and threats to the patient and promoting a desirable pregnancy outcome. Ethical issues should be upheld and accurate documentation is paramount.

References

Decherney, A. H., Nathan, L., Laufer, N., & Roman, A. S. (2019). Current diagnosis &    treatment : obstetrics & gynecology. Mcgraw Hill Education.

Park, K., Wu, P., & Gulati, M. (2020). Obstetrics and Gynecological History. JACC: Case Reports, 2(1), 161–163. https://doi.org/10.1016/j.jaccas.2019.11.035

Smith, R. P., & Netter, F. H. (2018). Netter’s obstetrics & gynecology. Elsevier.

Choose a special population and detail the approach to history taking and physical examination with the patient and/or family member.