History and Physical examination

Dr. Raheq Abu shogair

Obs&Gyn specialist
 History
• Profile
- LMP , EDD , GA
- Gravidity & Parity
- Blood group
• LMP : 1st day of bleeding of the last menstrual
cycle
• EDD : expected date of delivery ( due date )
• Gestational age
• Gravidity : No. of pregnancies regardless to
outcome
• Parity : No. of pregnancies delivered after the
age of viability ( 24 weeks )
• GxPy+z
• If Pt. is pregnant : X= Y+Z+1
• If pt. not pregnant : X = Y+Z
• Chief complaint + History of present illness
• - analysis for chief complaint
• - interventions before and after admission
( investigations , US, CTG , IV fluid , etc. )
• History of current pregnancy :
• - planned or not / spontaneous or assissted
• - How she knows she is pregnant
• - booking visit
• - supplements
• - investigations
• - complications
• - Hospital admissions
• Past obstetric history
• Previous pregnancies : year, spont or not ,
mode of delivery , if CS indication ,outcome,
wt. , NICU admission , A& W, complications
during pregnancy or delivery
• Past Gyn History :
• - menstrual cycle history ( regularity ,
occurrence , duration, amount )
• Previous Gyn. Procedures
• Pap smear
• Vaginal discharge or vaginal swab
 Physical Examination
• Abdominal :
• Inspection
• Palpation : leopolds maneauvers
• Auscultation

• Vaginal :
• - inspection
• - digital vaginal examination