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