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HISTORY IN OB/GY. AHMED ABDULWAHAB. Personal history , age ,occupation, duration of marriage if she is married . Last menstrual period LMP. Complaint . On the patients own wards. History of present illness. Starts from the time of the complain .
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HISTORY IN OB/GY AHMED ABDULWAHAB
Personal history , age ,occupation, duration of marriage if she is married . • Last menstrual period LMP. • Complaint . On the patients own wards. • History of present illness. • Starts from the time of the complain . • Some patients may not have a complain as those admitted from the clinic.
History of present illness should describe the full analysis of the complain , onset, duration , characteristic of the main complain any associated problems and systemic inquiries . • OBSTETRIC HISTORY. • Previous pregnancies should be reviewed in chronologic order with these information
Date of delivery. • Duration of gestation in weeks . • Type of delivery. SVD , C/S, or instrumental delivery forceps or ventouse. • Duration of labor . • Maternal complications. • Neonate weight gender and any complications
Gynecological or menstrual history. • How to calculate the expected date of delivery. Nageles rule , add 7 days to the first of menstrual cycle and subtract 3 from the month. • Example. LMP 13- 09 – 2011. • EDD IS 20- 06- 2012. • Regular cycle or not
Dysmenorheoa, painful menstruation • Dyspareunia, painful coitus . • Post coital bleeding • Contraceptions . • Vaginal discharge . • In infertility case you should take history from the husband .
HOW YOU LAY DOWN NUMBER OF PREGNANCIES AND ABORTIONS ? • Gravida means the patient is pregnant now . Parity is used for the number of previous pregnancies more than 24 weeks • + is used for the number of abortions, ectopic pregnancy , molar pregnancy.
EXAMPLES . • A woman who is having 3 deliveries before and one abortion and now she is pregnant • You will say she is gravida 4 para 3+1 • First pregnancy will call them primigravida.
Medical history any significant medical diseases DM , HTN . • Surgical history for any significant surgical procedures . • Social history , habits , smoking, alcohol, drugs abuse .standard of life, socioeconomic status . • Drugs and sensitivity