HISTORY TAKING FOR OB-GYN CASES

ID :Name , Age , lady , Nationality , living & originally , Occupation

G P + or G T P A L
LNMP & EDD & GA .

C/C :
HPP or HPI :

-current pregnancy :
The pt. was diagnosed to be pregnant after she missing her period for ( ) wks by
(blood (2wks) urine (5wks) ) tests which done in ( / / ) . She gave Hx of (N/V/
hyperemesis gravidarum) in early wks for about….
ANC (regular, where, when start, last visit, complication )
U/S ( 1st US done(16-20wks), where, when, result, other US )
Fetal movement (1st one notice at (16-20 wks), regularity, continuous.
Medications (folic acid , iron , vitamins , OCPs , other )
Weight gaining(10-15Kg)& blood glucose screening(24-28wk)
Hx of ( DM , HTN ,UTI ,Vaginal bleeding or discharge , fever)

-current complain:
pain: Site, radiation, Nature, Relation to periods, Aggravating and relieving factors,
associated SS
Vaginal discharge: amount, color, odor, blood, rash, pain
Micturation and bowel: Frequency of micturation increase, incontinence (real or
stress), urgency, dysurea, hematurea, Loin to groin pain
Investigation done to her (BSP, Hb , Bp , US , X- ray …)
Risk factor

-partum & postpartum Hx :

She is now ……. Days postpartum & can go to bathroom .
Labor pain(start on…, regular, increase in frequency, occur every… min,
spontaneous or induced, duration )
ER , DR (what done , drugs , anesthesia , episiotomy , laceration )
Mood of delivery (FTNSVD ,C/S ) & result (Boy or Girl , Wt , condition of baby )
Lochia ( start after delivery, color, quantity, smell, increase or decrease )
Symptom of infection ( fever, tachycardia, headache, abdominal pain, back pain )
 Symptoms of pulmonary embolism (cough, sputum, hemoptysis, chest pain,
dyspnea )
Symptoms of mastitis ( breast pain, tenderness, hotness, swelling )
Symptoms of UTI (passed urine ……hrs after delivery , urine retention or
incontinence, frequency, dysuria, loin pain )
Bowl habits ( constipation , diarrhea )
Symptoms of DVT (leg pain, swelling, hotness, mobility, fever(after 4-10 days))
Mood of pt. (anxious , depressed )
Post partum fever or distended abdomen .

Menstrual History
Menarche: (age , cycle days/ interval from first day to first day of next period,
duration of bleeding, regularity, normal amount, No. of tampons or pads staining
use , dysmenorrhea (1ry or 2ry), intermenstrual bleeding, post coital bleeding,
dyspareunia, Contraception ( IUCD, condoms, OCP…)

Obstetric history:

age & FT or NSVD Wt. PP- Where Breast Alive ANC Nursery
sex PT& assisted complc &anast Feed or died DM
GA C/S ation hesia or not HTN
G1

G2

If there is Hx of Ectopic or Abortion ( when, GA, D&C or E&C, post op.

complication, cause, painful or not )
What is the cause of gab b/w babies (OCP)(which, when, how long)

Past medical & surgical history:

DM, HTN, SCD, Myomectomy, abdominal surgery, blood transfusion .
Family history:
FH of (HTN, DM, SCD, Thalassemia, epilepsy, twins, TB, Malformations,
Infertility )

Social history:
House wife or working mother(load heavy or not ), education, living status,
socioeconomic state, smoker, alcoholic, habits, her husband (work, old, health,
relation b/w her & her husband, relativity )
How long she married ?

Drug and allergy history: OCP, induce ovulation & Teratogenic drugs .

Systemic review :
Summary :

Done by: Abdullah Al- Suwaidan