By the Name of Allah

SINNAR UNI. OBS & GYN Department (2009 & 2010) - batch 13 - 14

HISTORY TAKING IN OBS-GYNE

I’m going to present…………………………………………………… (Full Name).
Name: my pt. ……
Age: she is……. Yrs old,
Residing…………....
Occupation: she is a house wife/…….
Tribe:…….. , Educated till ………....
-she is married since…………. yrs. ago, to……………………………….
he is ………………………. (his job)
No / consanguinity between him……………………….

C/O: - She was admitted in …./…../ (or …. Day ago)

Because she had………………………………………
-for Elective C/S
-watery vaginal discharge/ gush of fluid /drain of liqour

Concerning her *GYNAECOLOGICAL history:

Menarche:
- She had her 1st menstrual cycle when she was……....yrs old.
Katamena: Cycle days/ interval from first day to first day of next period,

- Her cycle come every……. Day and last for……….. days.

Or( she used to have regular menstruation every…..,)
Regularity: it was regular, Amount of flow: average in amount
important b/c may indicate fibroids or endometrial polyps if too heavy
Ex. -Any intermenstrual bleeding
- post-coital bleeding –cervical polyp
- Not associated with / clots or/ dysmenorrhea.
- Not preceded by any vaginal discharge
- She dont / use contraceptive pill .coz ("COC" post-pill amenorrhea,
lactation)
Other wise,
- She did not expose to radiation
- She not take any Drug.

- Her L.M.P was in …………………….

make sure you specifically ask about the first day of the cycle
(TOavoid prematurity?)
uncertain Date: (ask fetal movement , public occasion, 1st ANC visit U/S)
This make her E.D.D at …………………..
Naegle’s rule:
EDD= LMP + 7d – 3 mths (or + 9 mths)
 week month
4wk 1st
Obstetric history:
8wk 2nd
-G.A : How many weeks pregnant now
13wk 3rd
-she is /not on in regular ANC. (how many freq.?) 17wk 4th
Gravidity and parity: 21wk 5th
-my pt. is ………………………… 26wk 6th
(gravida#, para#, +misscarige ) 30wk 7th
34wk 8th
delivery of twins is considered one gestation & 2 paraity ;.
Any delivery <24weeks is an abortion- (significant 3or more)
Any delivery >24weeks is para
Ectopic pregnancy is mentioned extra+

SNVD (Spontaneous Normal Vaginal Delivary)

-attended by trained Midwife
-uneventfull
- without complication to mother or baby.
Birth:her 1st pregnancy:
term ,normal vaginal delivery /C-section
Born home/hospital
Single Male/female baby,
Weight (average 2.5-3.5 kg )
PP complications / -uneventful purperium/or purperia.
Breast fed
Baby alive and well / died after……
Ex. 1989, FTND, in hospital, male baby, 3.5 kg, no PP complications, breast fed

-Ask about the Date of last delivery: when?...yr ago ( spacing, family planning)
Complicated birth:
C.S for APH
Ex. 1986, C.S for APH, female baby alive 3kg, post op normal, breast fed

-My pt. have had…………….

Abortion:
Year: at ….. (Gestational age ) month
Evacuation
Post Op complications
Ex. 1990, abortion at 3mo , evacuated at hospital , no post operative complications
Ex. 1992, abortion at …., D&E, blood transfusion

Ended by emergency C/S

Due…………(indication must be mention)
Was done in ……….(place)
Current pregnancy: ( dont say current pregnancy in primgravida)

-1st Trimester :
-Nausea & vomiting

-Vaginal bleeding

-fever

-drug / tonics

-expose to irradiation

2nd Trimester :
-Quickening; When first fetal movements were felt
(quickening, in a primi gravid around 18-20wks, in multipara 16-18wks)

-UTI
Pt. not complaining from UTI
-Vaginal bleeding

-Tetanous Toxoid Vaccin

She completed her Tetanous toxoid &not need any
more dose./ she didn’t received anti-Tetanous vaccine.

3rd Trimester :
-she still appreciate fetal movement
-vaginal bleeding
History of the present complaint:(HPC),,(HPI)
Chief complaint,
(My pt. was well until …....days prior to adddmision , when she start to develop
(…………………………………………………………………………………)

Abnormal menstrual loss:

pattern, regular/ irregular
Amount of loss
# of pads or tampons used
passage of clots or flooding
any pain with the loss

if the complain was pain:

Site, Nature, Relation to periods, Aggravating and relieving factors, associated
…………………………………………………………………………………………
…………………………………………………………………………………………

Vaginal discharge:
Onset , Amount, constant/ on&off ,regular/irregular,
Color , odor, itching , preceded fever or rash, ass e pain , reliving&agrevating
Convulsion :
prodormal symptomes ,describe convulsion type…, recovery stage.

Systemic review
-CNS : headach, loss of conscious, blurring vision,fits…
-CVS : cough ,palpitation. SOB
-RS
-GIT : epigastric pain
-Renal
-Muscloskelatal

Micturation and bowel:

Frequency of micturation increase d/t pressure and irritation.

Urine retention is d/t the effect of progesterone which relaxes the bladder muscles ,
and the rectum muscles leading to incomplete emptying of the bladder and
constipation.
A high fiber diet is suggested and laxatives may be prescribed.
Ask about: incontinence (real or stress),
urgency,
dysurea, hematurea
Loin pain
Regarding her

Past medical & surgical history:

Especially (gynecological)surgeries on the uterus; myomectomy removal of
fibroids
Hx of infertility
Hx of abdominal surgery may cause adhesions
-she never exprince DM, HTN, Renal disease,Bronchial asthma or epilepsy
- she not recived Blood transfusion before

Concern her Family history:

There is /no
HTN
DM
Renal disease
Twins/
Congenital Malformations
multiple pregnancy

Drug and allergy history:

-she is not alleric to any drug known to her
-she is not on long term medication
- now she is on:…………………..
Teratogenic drugs; ACEI, Warfarine ,phenytoin, cytotoxic drugs, tetracycline,
chloramphenicol..

Social history:
-lives in: ( separate, rent/ family house)
- not breeding animal
- good / electrical & water supply
House wife/ working mother
Smoking; ask about shisha as well
Drinking
Husband’s profession
-socioeconomic status.( high, modrate, low)

In summary :
Age: ……. Yr old lady
She is( primgravida, multipra)
She is running her …. Pregnancy, now her Gaesteationl age is ….
Indication : admitted ……days ago , c/o ………..,for further investigation
&management.

-most likely be:-professional diagnosis.

 Physical examination of OB-GYNE

General:
Appearance: pt. looks……… ill/well, height&gait,limbing,in pain/or not ,
obese/thin, anxious/ depressed

Pallor –
Jaundice –(D.D?) (sever PIH, HELLP,hepatitis, cholestatic, acute fatty liver)
Cyanosis

-oral: Artificial dentations (why?)

Dental caries
Sign of iron deficiency
-neck:
Pulsation , JVP ,

thyroid ,

trachea, cervical lymph node…..

Vital signs:
Pulse (+15b/m)-( large volume, collapsing"placenta act as A-V shunt)
(palmr erythema, high ESR normal in pregnancy)
- BP - Temp - RR

Systemic review:
Respiratory system
CVS
Breasts examination:
-inspection:size, nipples (everted) , fissure and cracles, pigmentation,
Montogomrys tubercles & nipple discharge , 1ry &2ry areola.
Palpation: 6 area & axillary lymph node.=> lump

ABDOMINAL EXAMINATION:

Inspection:
Abd. Uniformy distended , full flanks , striae gravidarum , kicking, bulges, scar
Umbilical ( flat, inverted, ) linea albicans/nigra, rash, pigmentation

size and shape:

midline fullness indicates ovarian or uterine mass.
Fullness of flanks suggests ascites (confirm by fluid thrill and shifting dullness),
iliac fossa masses usually ovarian or bowel.
Palpation:
I will procced to …..
Superficial: tenderness, mass, Temp. , liquor amount

Deep: for organomegally ( turn pt. to left "liver" or/ right side).
  Mass: position, size, shape, edges, mobility, consistency, fluid thrill if
cystic
Malignant tumors usually fixed. Mobile tumors usually benign, but may be
fixed by adhesions.
 The Fundus
 Fundal height: (correct Dextrorotation, use ulnar surface)=> to land mark
(from S.pubis uptil the fundus "symphsio-fundus" in cm. by tape..
- move downwards from xeiphisternum to fundus ( 1finger= 2week).
-If by calculation 38 and measure 26 it means there is either a miscalculation
of the EDD, or a problem with the fetus as IUGR.
-Also if the opposite, the calculation<measured, it may suggest a macrosomic
baby, twin pregnancy, polyhydramnios, hydropis fetalis.
- correspond to date: / equivalent/or more/less than date)
 Fundal grip:
to see whether the (head /or the buttocks are occupying the fundus/ or empty.
Cephalic presentation
head is down and the buttocks(broad,irregular)occupy the fundus.
Breech presentation
is when the head (round,hard,palatable) occupies the fundus.
This is significant esp in a primigravida where C-section is preferred.
 Lateral grip:
important to assess how the baby is lying; whether transverse, oblique or
longitudinal, the latter being the only ideal position for delivery. It also tells
whether the baby’s back is on the right or left.75% of baby’s backs are on the
left probably b/c of the liver on the right. This is necessary to find the site to
auscultate for the baby’s heart beat.( shoulder)
 First pelvic grip:
The only position with the back to the patient
see what presenting part of the baby (head) occupies the pelvis
 Second pelvic grip:( face to feet but look to pt. face)
if mobile, then it is not in the pelvic brim, so no engagement has occurred yet.
If immobile it means that the BPD (biparietal diameter) of the baby is in the
pelvic brim; i.e engagement occurred (role of fifth). This palpation is
necessary esp in primigravida b/c if 36 weeks passed and no engagement
occurred, it may suggest that the pelvis is too narrow, or the baby has
hydrocephalus etc..

*EXAMINATION summary:

Auscultation:
Fetal heart:(120-160 b/m) heard with Pinard stethoscope after
LL . examination:
Oedema (1 inch above medial mallulos , 1 finger, 1 minute)
Varicose veins (in calf, thight, vulva), - pulsation