Gynae/Obs History Pattern


History
Biodata:
Name: Mrs.
W/O: Mr.
Age
Sex
Address
Occupation
Duration of marriage
LMP
G.p.a
Edd
Gestational age
D.o.A
M.o.A

P.c- write period of amenorhea if present
HOpI: hw did she cnfrm pregnncy? Any antenatal care.
1st trimester history: booking, nausea, vomiting, drugs, fever, spotting, urinary symptoms. etx
2nd trimester: usg done? Quickening, cmplaints of HTn, diabetes, pv bleed, edema, urinary micturition, urgency etc
Third trimester: Tetanus vaccination? Pain? Leakage? Bleeding? Fetal movemnts?
Detail of present complaint.(bleeding k sath ae tau provoking factor)

Obstetrical history: gravida para aborted? Delivery of previous children? Ne cmplications? If ne loss then reason of loss?Duration of gestation of previous children? Gap btw children?gap in 1st children n marriage? Period of lactation?
Gynae history:
Age of menarche, menstrual cycle n amount of bleeding? ne use of cntraception? Vaginal discharge? Pap smear test? Vaccination? Intermesntrual post coital

Past history: med+surgical
Family history
Personal: sleep pattern, stress, marital relations,smoking etc
Drug history:
Socioeconomic status:
Systemic review
GpE
Systemic
Abdominal: inspection+palpation+leopold+auscultate

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