Golden Rules 1- The history needs to be taken in a logic and chronologic sequence 2- It needs to be narrated and presented in English

3- All items of the history need to be fulfilled 4- You should start by presenting the preliminary data about the patient before embarking on the history of the present illness or pregnancy 5- Start your presentation by presenting yourself to the audience: e.g. I am .., a 6th year medical student and I am presenting the case of Mrs. .. Sample History Taking Personal history Mrs.. is a .year-old lady married for and having living children. She lives in ..and has no special habits of medical importance (or otherwise: she is a light smoker for the past years, etc). Her husband Mr..is ..years old. He is working asand has no special habits of medical importance ( or else.) Complaint Mrs. ..was admitted to the hospital complaining of.. If the lady is pregnant you should state that before the complaint. E.g. Mrs. is 5-months pregnant. She was admitted complaining of sudden gush of watery vaginal discharge 3 days ago and persistent till now. Menstrual history She had her menarche at the age of..Since then she used to have regular cycles at .days interval with days average menstrual flow. She is experiencing mittle schmirz and ovulatory cascade. There is also mild congestive dysmenorrhea responding well to NSAIDs. Her Last normal menstrual period was on If She is pregnant: Her LMP was on making her EDD on She is currently ..weeks. Contraceptive history She inserted an IUD after delivery o her first baby. She used it for 5 years and removed it because she wanted to get pregnant (or otherwise: because it caused menorrhagia)

Sexual history Inquire about it in case there is a need e.g. cases of infertility or if the complaint is related to the couple sexual performance. Be discrete, courteous, respectful and confidential. Ask about o It may be wise to ask a general question about this issue e.g. Do you have any problem in your relation with you husband? o Whether she is sexually active or not o Frequency of intercourse o Whether there is any element of dyspareunia o Whether there are any precoital or postcoital rituals o Whether she and her partner are satisfied by their sexual experience Past medical history This will include her detailed previous medical / surgical disorders. E.g. Mrs..is diabetic for the past 15 years. Her diabetic condition is controlled by Insulin. Or shes been subjected to appendectomy 4 years ago,. She remained hospitalized for a week because of wound infection. Or simply she is giving no past history of medical importance Past obstetric history 2-digit code * P..++ or 4-digit code *G; TPAL+ Including all deliveries and abortions You may combine several similar deliveries in case of high parity E.g. A Gravida 6, 4113 or G5, P4+1 o All her pregnancies but the last ended at term after an uneventful antenatal period. She delivered a spontaneous vaginal delivery at home and was attended by a traditional birth attendant. She gave birth to 3 living boys of average weight. There were no intrapartum or postpartum complications. She breastfed her babies. They are alive and well . o In 2005, her last pregnancy ended prematurely after spontaneous onset of labor during the 34th week. She delivered by cesarean

section and gave birth to a 2.00kg girl who was incubated for 3 days then died from respiratory distress o Her 2nd pregnancy ended at 10 weeks by spontaneous abortion completed by Evacuation of retained products of conception (ERPC) at hospital. Family History She and her husband are 2nd degree consanguineous couple Her father and mother are diabetics Or : she is giving no family history of medical importance History of the present Illness or Pregnancy The history of the present illness or pregnancy represents a detailed analysis of the patient complaint. It starts with the last time the patient was symptom free; For a pregnant woman it should therefore starts with the Last menstrual period. It needs to then include the following: o When and how pregnancy was diagnosed and confirmed o Early pregnancy symptoms and how she dealt with them o If she is followed up antenatally (already booked for antenatal visits or not yet + number of antenatal visits) o Investigations done so far o Quickening o What brought her to the hospital and analysis of her complaint (s). o What investigations were done since admission? o Did she know about her management plan? Analysis of the history and formulation of a diagnosis and decision making This is the culmination of the history. It needs from you to have a global understanding of the different segments of the history. It needs to be formulated as follows: o Mrs. ..is a 30-year old lady Gravida 4th, 0300 admitted to the hospital at 32 weeks gestation with the diagnosis of threatened preterm labor. She is put on tocolytic therapy and was given corticosteroid to promote fetal lung maturity.