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Obstetrics & Gynecology History

A: Personal and social history
    Name, age,work, marital. address, habits, smoking,alcohol,drug abuse, Domestic pets, Dogs, Cats, Birds, Farm animals.
B: Menstrual history
C: Obstetric history
D: Past history
E: Family history
F: Contraceptive history
G: Complaint
H: History of Present Pregnancy
I: History of Present Illness
J: Provisional Diagnosis

Personal and social history
1: What is your real, birth name?
2: Where and when were you born?
3: How old are you?
4: What is your Email address?
5: What is your mailing address?
    What has been your mailing address from the time of your birth until now?
    What language do you speak?
6. What is your normal day like?
7. Do you smoke?
8. Do you use alcohol?
9. Do you abuse any drugs?
10. What is your height?
11. What is your weight?
12. What is the color of your skin?
13. What is the color of your hair?
14. How many children do you have?
15. How many brothers and sisters do you have?
16. Do you have any domestic pets?
17. What food do you eat every day?
18. What is your favorite food?
19. How many meals do you have each day?
20. How long do you wait between two meals?
21. What is the minimum clothing or outer garments, jackets, underwear, socks, and shoes should you have?
Outer garments can be Kurta and pajama, trousers and shirt. There should be four winter jackets and seven underwear. This doesn't include outfits for running or sports.
22. How often should you do your laundry?
23. Do you have a spouse?
24. Did you have a spouse?
25. What do you understand by spouse?
Obstetric history

How do you define a family?
What language does your spouse speak?
Where did your spouse go to high school?
Where did your spouse go to college?
How many total deliveries did you have?
What do you understand by full-term, preterm, miscarriages or abortion?
How many full-term deliveries?
How many preterm deliveries?
How many miscarriages?
How many are living?

Contraceptive history

The case history is essential for correct diagnosis and proper case management.
When did you first have intercourse?
How old were you?
What do you understand about intercourse?
How do you feel?
Are you sexually active?
What method of contraception are you currently using?
When did you start it?
Did you have any side effects?
What contraceptive methods have you tried previously?
When did you start using that contraceptive method?
Where did you procure it?
Why did you stop it?

With how many different people have you had intercourse up to now?
How many times have you had intercourse up to now?
What was the location?
Were you raped?
Have you ever been raped?
Where you ever molested?
What do you think is the difference between rape and molestation?
What is your normal day like?

Do you or have you had gestational diabetes?
yes no

Do you or have you had preterm labor?
yes no

Do you or have you had high blood pressure?
yes no

Have you had a previous cesarian section?
yes no

Has your labor been induced in your previous pregnancies before your due date?
yes no

Has your labor been induced in your previous pregnancies on or after your due date?
yes no

Sexually active or not

Taking a Sexual History

Given that women now live approximately one-third of their lives after menopause and continue to be sexually active beyond the cessation of reproductive functioning, the sexual history should now be a routine component of the annual clinical visit of the woman in midlife and beyond.1 Kingsberg suggests that pre- and postsurgical visits (for uterine prolapse, hysterectomy, oophorectomy, mastectomy, etc.), as well as those related to menopause, chronic illnesses, and depression, also lend themselves to inclusion of assessment for sexual disorders.2 Starter Questions

Contraception and Risk of Unintended Pregnancy and STIs in Perimenopausal and Menopausal Women Women over the age of 40 have the second highest proportion of unintended pregnancies, so the need for effective contraception continues into midlife until menopause.3 No contraceptive method is contraindicated by age, and certain methods, such as oral contraceptives (OCs) and other hormonal methods, may stabilize hormone levels and ease the transition through menopause.3,4 The decision about which method to use should be guided by patient preference, lifestyle, behaviors (e.g., cigarette smoking), and medical history.3,4 Safe-sex practices should be discussed with all patients regardless of their age or sexual orientation.

Are you currently involved in a sexual relationship?
Do you have sex with men, women, or both?
Are you or your partner having any sexual difficulties or concerns at this time, or do you have any questions or concerns about sex?

More extensive questioning can include the following:

Are you satisfied with your current sexual relations?
Do you have any sexual concerns you wouldlike to discuss?

If a patient responds with answers suggesting she has concerns and wants to discuss them, you might then proceed as follows:

�Tell me about your sexual history�your first sexual experiences, masturbation, how many partners you�ve had, any sexually transmitted infections or past sexual problems you�ve had, and any past sexual abuse or trauma.�

�How often do you engage in sexual activity?�
What kinds of sexual activities do you engage in?
Depending on the sexual orientation of the patient, ask about the specific forms of sex, including penis in mouth, vagina, or rectum; mouth on vulva.
If the woman is a lesbian, ask if she has ever had penetrative sex with a man, to assess her risk of cervical cancer and sexually transmitted infections.
�Do you have difficulty with desire, arousal, or orgasm?�
If the woman is peri- or postmenopausal, preface these questions with information that many women often experience vaginal dryness and changes in sexual desire around the time of menopause.

Along with sexual activity questions, a standard menstrual and obstetric history should be obtained, inquiring about the age of onset of menses, last menstrual period, characteristics of menstrual periods, problems associated with menses in the past, pregnancy-related problems, and perimenopausal/menopausal symptoms.2

Physical Examination

A comprehensive physical examination should be conducted to detect potential contributors to or causes of sexual problems. This examination, which should be conducted with close monitoring and input from the patient to isolate potentially painful areas, should also be used to educate the patient about her reproductive anatomy and sexual functioning.


Menstrual history

First day of the Last menstrual Period (LMP)
When was the first day of your last menstrual period?
Normal range

Dates: Regular? Sure? Reliable?
Details for gynecologic sheets:
Dysmenorrhea (spasmodic, congestive, etc.)
Premenstrual syndrome

Obstetric history

Parity: outcome of previous pregnancies
Gravidity: order of the current pregnancy (if
pregnant now)
Delivery:>28 weeks
Miscarriage: <28 weeks
Systems of terminology
Gravida _____, Para ___
Para a + b (a=delivery, b=miscarriage)
Para a,b,c,d
a= full term delivery
b= preterm delivery
c= miscarriage
d= ?living

Details in an obstetric sheet (Chronolically):
1) Date
2) Place
3) Mode
4) Maturity
5) Fetal life
6) Fetal sex
7) Fetal weight
8) Onset of labor
9) Antenatal complications
10) Postnatal complications
11) Neonatal outcome
12) Breast feeding

Contraceptive history

Pap smear


Past history

Surgical & anesthetic
Hospital admission
Blood transfusion

Medical history
Hypertension- Diabetes mellitus
Bleeding tendencyThrombophilia

Family history
Similar conditions as to patient complaint
DM or hypertension
Familial disease e.g thrombophilia, bleeding tendency, PCOS
Fetal anomalies or inborn errors of metabolism
Main complaint
In the patient's own words.
Duration of the complaint.
History of current pregnancy of illness
Analysis of the complaint
Onset, course, severity, duration
What increases/decreases the symptom
Associated symptoms
Others symptoms to prove.disprove
the provisional diagnosis
Investigations done (date, place & results)
Treatment recdeived (details and response)
Any complications
Obstetric symptoms
Emesis gravidarum
Urinary disturbances
Fetal kicks & quickening
Passed Show
Antenatal care
Preg test
Bl. sugar
As needed
Gunecologic symptoms
B:Bleeding pv
C:coital difficulty
P:pruritus vulvae
Family-Centered Maternity Care-Pregnancy

Prenatal care
Pregnancy (Initial profile)
1st Trimester
2nd Trimester
3rd Trimester
Medical termination of pregnancy.
Who decides?
Who terminates?

What are the indications of medical termination of pregnancy?

In case the pregnancy is the result of rape or conspiracy.
The woman could not cope with labor.
Due to ailment, the woman would not be able to bring up the child with love and care.
Even if any other person or group comes forward and takes responsibility for bringing up the baby, pregnancy can't go ahead.
We are dealing with a human being.
There is a difference between human pregnancy, family-centered maternity care, and poultry farms.
Other medical indications.

What should happen if these guidelines are violated?
Dishonorable discharge from service with punishment.

Who may violate these guidelines?
Medical doctors, judges, director of health, secretary of health, head of the state, county, city, and others.

Do you know any such situation or incident?
Premature Labor
Management of the First and Second Stages of Labor
Cesarean section

What is an episiotomy?

What is a cesarean section?
When is a C-section needed?
What are the risks of C-section?
How is a C-section done?
How long does it take to recover from a C-section?
Why would I want to avoid a cesarean?
Hypertension in Pregnancy
Diabetes in Pregnancy
Irregular Menstrual Periods
    Have you been experiencing high levels of stress?
    How much do you exercise?
    Have you ever had an eating disorder?
    Have you lost weight recently?
    Have you been intolerant of heat or cold?
    Have you had rapid heartbeats, dry skin, hair loss, constipation or diarrhea, or a change in weight (these are symptoms of thyroid abnormalities, which can cause irregular periods)?
    Do you have abnormal body hair?
    Have you gained weight?
    Do you have regular menstrual cycles?
    Is your bleeding always heavy or prolonged?
    How old were you when you started menstruating?
    How long ago did you develop irregular periods?
    When you do have your period, is it accompanied by symptoms such as abdominal cramping, mood changes, and bloating?
    Are you sexually active?
    When was your last period?
    How many times have you been pregnant?
    What was the outcome of each pregnancy (live births, miscarriages, cesarean sections)?
    Have you ever had difficulty getting pregnant?

    Your Doctor Might Examine the Following Body Structures or Functions:

    Heart rate, blood pressure, and weight
    Heart and lungs
    Pelvic examination

    Your Doctor Might Order the Following Lab Tests or Studies:

    Pregnancy test
    Blood tests for certain hormone levels (thyroid stimulating hormone, cortisol, prolactin, follicle stimulating hormone, 17-hydroxyprogesterone, testosterone, DHEA)
    24-hour urine collection for free cortisol
    Pelvic ultrasound
    Pap smear

Diagnosis and Management of Intrauterine Growth Restriction
Spontaneous Abortion
Postpartum Blues, Depression and Psychoses
Evaluation and Management of Cervical Abnormalities
Postmenopausal Symptoms and Their Sequelae
Dysfunctional Uterine Bleeding
    Do you have regular menstrual cycles?
    Is your bleeding always heavy or prolonged?
    How old were you when you started menstruating?
    How long ago did you develop abnormal bleeding?
    Have you gone through menopause yet?
    Are you sexually active?
    When was your last period?
    How many times have you been pregnant?
    What was the outcome of each pregnancy (live births, miscarriages, cesarean sections)?
    Have you ever had difficulty getting pregnant?
    What medications are you taking (including over-the-counter drugs and herbal remedies such as ginseng)?
    Are you taking hormone replacement therapy or birth control pills?
    Have you ever had medications injected (Depo-Provera or Norplant) for birth control?
    Have you ever taken estrogen or tamoxifen?
    Are you taking warfarin or other blood thinners?
    Have you ever had cancer of any type?
    Have you ever had an abnormal Pap smear?
    Do you bruise easily?
    Do your gums bleed?
    Do you get nosebleeds?
    Do you have a blood-clotting abnormality or does one run in your family?
    Do you have kidney or liver disease?

    Your Doctor Might Examine the Following Body Structures or Functions:

    Blood pressure, heart rate, weight
    Abdominal examination
    Pelvic exam

    Your Doctor Might Order the Following Lab Tests or Studies:

    Pregnancy test
    Blood tests such as complete blood count, coagulation (clotting) studies, and certain hormone tests (such as thyroid stimulating hormone, cortisol, prolactin, follicle stimulating hormone, testosterone)
    Pelvic ultrasound
    Pap smear
    Rare Endometrial biopsy
Ectopic Pregnancy
Management of Contraception
Response and management to other disasters
Sexually Transmitted Disease
    What is contraception?
    What different types of contraception are there?
Premenstrual Syndrome
    Q) What Is Premenstrual Syndrome?
    Q) What Are The Symptoms Of PMS?
    Q) What Causes PMS?
    Q) What Hormones Cause PMS?
    Q) How Do Hormonal Changes Cause PMS?
    Q) Could Calcium And Magnesium Imbalances Be Involved?
    Q) Does Stress Cause PMS?
    Q) How Can I Tell If I Have PMS?
    Q) Should I Get Treatment For PMS?
    Q) What Treatments Work?
    Q) What changes in diet can help?
    Q) How can physical activity help?
    Q) What about stress management?
    Q) What other non-drug treatments can help?
    Q) What Medicines Can Help?
    Q) How Can I Treat Specific Symptoms?
    Q) Where should I start?
    Q) Will PMS get worse?
    Q) Do women with PMS have different hormone levels?
    Q) Can PMS mimic other diseases?
    Q) Can my PMS be depression?
    Q) Can PMS worsen other medical and psychiatric problems?
    Q) What about a woman with PMS on the birth control pill?
    Q) Can I have PMS when I am not menstruating?
    Q) Can I get menstrual A word referring to the normal monthly cycle of women which results in a period each month. The one to two weeks before the period is called premenstrual. cramps if I have PMS?
How might a disorder present differently in women than in men?
Why are women at risk for certain conditions?
What pathophysiologic aspects of disorders are unique in women?
What type of interventions are appropriate?