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Chapter-30 Common Mistakes in Case Presentation

BOOK TITLE: Clinical Obstetrics—A Case-based Approach

Author
1. Singh Nilanchali
2. Mishra Pushpa
ISBN
9789352702749
DOI
10.5005/jp/books/14196_31
Edition
1/e
Publishing Year
2018
Pages
5
Author Affiliations
1. Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
2. Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, Lok Nayak Hospital, New Delhi, India, Maulana Azad Medical College and Lok Nayak Jai Prakash Narayan Hospital, New Delhi, India, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
Chapter keywords
History taking, breast examination, case presentation, fetal monitoring, trimester history, cesarean section

Abstract

The chapter lists out some common errors in history taking and examination by the medical students that come across while evaluating series of case presentations. First mistake, quite commonly done, is not taking history in patient’s language. Adding your own inferences in history is not a good idea. If the complaint of the patient is of a longer duration, and you have described it in detail, there is no need to again elaborate it in “trimester history”. You may simply mention “The patient presented with such complaints and was managed as described earlier”. The GPLA formula, i.e. gravida (G), para (P), abortion (A) and live babies (L) should be clearly understood and presented. While doing examination, patient should be explained about the full procedure and made comfortable. Breast examination should never be missed. Both normal and abnormal changes in pregnancy need to be mentioned. Condition like inverted or cracked nipple needs to be mentioned as they are very important part of patient and neonatal care. A common mistake is omitting important part of diagnosis, e.g. previous cesarean, while mentioning the diagnosis. One should never answer higher investigation before mentioning basic diagnostic ones.

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