Obs & Gyne

Case -1-

Name: 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 EDD gestational age

2. Planed or unplanned pregnancy

3. Conformation of pregnancy (how ,when ,whom)

4. Signs 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

2. Any abortion

#gynecological history 1. Menarche

2. Duration of the cycle +period

3. Amount of flow ? clots?

4. Pain with period

5. Intermenstrual or postcoital bleeding استخدم لفظ العالقة الزوجية

6. LMP

7. contraceptive history إذا كانت متزوجة

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 :

Name

Labor Spontaneous or induced

Mode of delivery

Alive Or still birth

Gestational age

Single Or twin

Gender weight Date of birth

Place of birth

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. Medical history (DM, HTN, Twins,)

2. Consanguineous marriage?

3. Any inherited disease (hemophilia , bleeding tendency )

4. Pre-eclampsia , chromosomal or congenital anomalies

5. 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.

**Hematological

• Generalized fatigability. • Any orifice bleeding(gum bleed, epistaxis ….). • Bruising or Skin discoloration. • light headedness. • Night sweating. • Weigh changes.

**Dermatological : • Rashes. • skin discolorations. • nail changes.

**Gynecological • 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.

**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. • fatigue

**Genitourinary

• Dysuria. • Red discoloration of urine. • Nocturia. • Frequency change. • Urgency, drippling. • Discharge. • Smell.

**Nervous system

• Headache. • Blurred vision. • Tinnitus. • Convulsions. • Neck pain. • Fainting. • Smell, taste change. • Numbness. • Muscle weakness.