Obs & Gyne

Case -1Name:
age
female patient, married for . Gravida..,
Para.., ., living . , occupation lives in .. blood group .
She was admitted through the .. on .. at ..
This history was taken by me Abdelrahman M sheikh Ahmad, from the patient herself who
looks informative and cooperative.
LMP:.. , EDD:. GA:..
Chief Complaint:

History of presenting complaint :

Systemic review:

#history of current pregnancy

.1

LMP

.2

Planed or unplanned pregnancy

.3

Conformation of pregnancy (how ,when ,whom)

EDD

gestational age

.4Signs and symptoms of pregnancy(missed period, headaches, tender breasts, nausea and
lower backaches, Fatigue, Mood Swings, Frequent Urination, Cramping, Cravings or Food
Aversions, Constipation and Bloating, Super Smell)

.5
Antenatal care and follow up (numbers of visits, investigation results, any problem of
any trimester , any drugs-duration +dose)

.6

Fetal movement

.7

Change in weight

.8

Any history of vaginal discharge or bleeding

.9

Any medical disorder before or throw pregnancy?(DM, HTN, Anemia, thyroid)

.10

Any previous stay in hospital during pregnancy

.11

Any specific screening test ( when and why?)

12.

Plan for delivery

Past obstetric history :

#past obstetric history

1. Duration of marriage
Name

Labor
Spontaneous
or induced

Mode
of
delive
ry

Alive
Or
still
birth

Gestationa
l age

Single
Or
twin

Gender

weight

Date
of
birth

Place
of birth

2. Any abortion

#gynecological history
1.
2.
3.
4.
5.
6.
7.

Menarche
Duration of the cycle +period
Amount of flow ? clots?
Pain with period
Intermenstrual or postcoital bleeding
LMP
contraceptive history

1. Current (what, when started ,any complications)

2. Previous (when ,what when stopped)
8. pap smear: Last one (when ,where , what was the result)
9. any other gynecological problems
10. prior difficulty conceiving
11. vaginal discharge

.Past medical and surgical history :

Any
complications
Or anomalies

Brest
feeding

#drug history or allergy:

Name ,dose , how long , when ,why, any complication, folic acid and iron

#family history:
1.
2.
3.
4.
5.

Medical history (DM, HTN, Twins,)

Consanguineous marriage?
Any inherited disease (hemophilia , bleeding tendency )
Pre-eclampsia , chromosomal or congenital anomalies
Fetal born error of metabolism

#social history:
1. Occupation
2. Income and medical insurance
3. Sick people contact
4. Travel
5. Level of education
6. Housing condition
7. Smoking & alcohole
8. Drug abuse
9. Marital state and support at home
10. Nuclear or extended family
11. Domestic animal

#any question ?
#summary,

#Systemic review.
**CVS (cardivascular system)
Chest pain.
Dyspnea/orthopnea/paroxysmal
nocturnal dyspnea(PND).
Claudication.
Syncope.
L.L edema.
Palpitation.
Cyanosis (central/peripheral).
**Respiratory system
Chest pain
Dyspnea/orthopnea/paroxysmal
nocturnal dyspnea
Cough, sputum.
Hemoptysis.
Wheezing.
hoarseness of voice.
Sore throught.
**Musculoskeletal
Athralgia or Myalgias.
Muscle weakness.
Morning Stiffness.
Redness, swelling.
Abnormal movements.

**Gastrointestinal Tract (GIT)

Oral ulcers.
nausea/vomiting.
hematemesis.
dysphagia/odynophagia.
heartburn/regurgitation.
abdominal pain/distension.
diarrhea/constipation.
melena/hematochezia.

Jaundice/Itching.

**Endocrine

Polyuria/polydipsia.
loss of appetite/hyperphagia.
changes in menestrual cycle.
Heat/cold intolerance.
Gain/loss of weight.
Skin /hair changes. (Bearded or bald
women and hairless men)

Sweating.
**Genitourinary
fatigue
Dysuria.

Red discoloration of urine.

Nocturia.
Frequency change.
Urgency, drippling.
**Hematological
Discharge.
Generalized fatigability.
Smell.
Any orifice bleeding(gum bleed, epistaxis .).

**Nervous system
Bruising or Skin discoloration.
Headache.
light headedness.
Blurred vision.
Night sweating.
Tinnitus.
Weigh changes.
Convulsions.
**Dermatological :
Neck pain.
Rashes.
Fainting.
skin discolorations.
Smell, taste change.
nail changes.
Numbness.
**Gynecological
Muscle weakness.
menarche age.
menstrual bleeding duration & amount.
length of the cycle.
presence of pain &its relation to bleeding.
the first day of last menstrual bleeding
contraception.
dysmenorrhea.
menopausal age.
postmenopausal bleeding duration & amount.