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Obstetrics & Gynecology History A: Personal and social 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 language do you speak? 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 Social 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. Spouse Menstrual history First day of the Last menstrual Period (LMP) When was the first day of your last menstrual period? Normal range Definitions: Menorrhagia Hypomenorrhea Oligomenrhea Amenorrhea Menopause Dates: Regular? Sure? Reliable? Details for gynecologic sheets: Menarche 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 (Controversial) Past history Medical Surgical & anesthetic Hospital admission Drugs used Allergy Blood transfusion Medical history Hypertension- Diabetes mellitus Cardiovascular-Respiratory Hepatic-Renal-GIT Endocrine-Neurological Bleeding tendencyThrombophilia Others 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 Malignancy Infections Complaint Main complaint In the patient's own words. Duration of the complaint. History of current pregnancy of illness Analysis of the complaint Symptoms 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 Bleeding ROM Contractions Passed Show Diabetes Hypertension Antenatal care Preg test BP Weight Ultrasound CBC/Rh Bl. sugar As needed Gunecologic symptoms A:Amenorrhea B:Bleeding pv C:coital difficulty D:discharge E:enlargement F:fertility G:galactorrhea H:hirsutism I:incontinence P:pain P:prolapse P:pruritus vulvae OTHERS SYSTEMS REVIEW Cardiovascular-Respiratory-Hepatic-Renal-GIT-Endocrine-Neurological |