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History Obs & Gynae PDF

This document outlines the key areas to cover in taking a patient history for obstetrics and gynecology. It includes collecting personal data, obstetric history including previous pregnancies and current pregnancy details, gynecologic history, past medical history, family history, social history, surgical history, and drug history. The summary at the end should include the patient's age, gravida and para details, gestational age if pregnant, and chief complaint.

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Maya Mohamed
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164 views4 pages

History Obs & Gynae PDF

This document outlines the key areas to cover in taking a patient history for obstetrics and gynecology. It includes collecting personal data, obstetric history including previous pregnancies and current pregnancy details, gynecologic history, past medical history, family history, social history, surgical history, and drug history. The summary at the end should include the patient's age, gravida and para details, gestational age if pregnant, and chief complaint.

Uploaded by

Maya Mohamed
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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History Obs & Gynae

 -Begins with greetings introduction and permission

-Personal data
name , age , blood group ,occupation , residence , tribe ,
marital status >> husbands name , consanguinity, age , occupation ,education , date of
marriage , cognately )
Date of admission .. Written like this
Ex: 11-1-2015

######################Complain Of ######################
Obstetrics history
1. Gravida... Para... +... (G…P..+…)
2. Ask about the Last menstrual cycle (LMP) >> first date of the patient's last menstrual
cycle to determine the expected date of delivery (EDD)
3. And the gestational age (GA)
For Ex: LMD>> 15-1-2015
EDD>> 22-10-2015
GA>> 13 weeks

* previous pregnancies
1. You ask the patient if she followed up or not ..
2. When were the previous pregnancies ?!
3. Induced or spontaneous
4. Any medications
5. Mode of delivery
6. Emergency or cold C/S
7. Any complications happened during the previous pregnancy
8. Outcome of the baby ( sex of the baby )
9. Was the baby well ?! And is he now ?!
10.Weight of the baby
11.Anomalies
12.Miscarriage ( evacuation >> by surgery or medicines )
13.Stillbirth
14.Sizable baby
15.Preeclampsia
16.Abruption of the placenta

*current pregnancy
1st trimester >>
1. early signs and symptoms of pregnancy ,
2. medications ,
3. radiation ,
4. vaginal bleeding ,
5. booking ( first antenatal visit )

2nd trimester >>


1. quickening ( first fetal movement ) 18-20 in primigravida , 16-18 in multigravida .
2. Vaginal bleeding ,
3. vaccination ,
4. symptoms of UTI ,
5. medications ,
6. antenatal followup .

3rd trimester >>


1. measure the blood pressure ,
2. fetal movement,
3. antepartum hemorrhage ,
4. ultrasound ( fetal growth , placental localization ) .
############################################################
Gynecology History
1. Menarche ( 1st menstrual cycle )
2. Kata
1. regularity ,
2. amount ,
3. frequency ,
4. duration ,
5. dysmenorrhea > pain associated with the period )

3. Vaginal discharge if present ask about


( type , color , odor , offensive or not , itchy )
4. Lactation
5. Contraceptive pills
6. Any gynecological operation
7. Last menstrual period
8. Dysfunctional uterine bleeding
############################################################

past medical history


1. diabetes mellitus ( gestational or diabetic already )
2. hypertension ( with pregnancy or hypertensive already )
3. bleeding disorder
4. psychiatric disorder

family history
1. HTN
2. DM
3. preeclampsia
4. any congenital anomaly
social history
1. smoking
2. alcohol
3. any housing problems

surgical history
1. when
2. mode of anesthesia

drug history
1. any long term medications
2. allergy to any drugs

###################################################

summary
Age , ( gravida... Para... +... ) , GA , C/O...................

done by :
Abdullah Fawaz
Earaa Hamza

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