Dr.Suresh Babu Chaduvula

Professor

College of Medicine

King Khalid University

Abha, KSA

Respect, confidentiality and privacy are

important

Information should be logical and also in

chronological sequence

History should guide a clinician to make a

provisional diagnosis and perform proper and

relevant investigations

To build a rapport with the patient

To come to a provisional diagnosis

To perform relevant investigations

To give correct treatment

To provide proper counseling

Seek permission from the patient, Greet the

patient

Dress code with Apron and identity badge

Make sure a sister or a female attendant be

with you.

Be gentle and sensitive

Biodata [ personal and social hstory]

Name :

Age:

Nationality:

Occupation:

Marital state:

Relation:

Wife/ Daughter of:

Address:

Obstetric Formula: Gravida, Parity, Abortions, Ectopic pregnancy

LMP

EDD

Gravidity – No. of pregnancies including this pregnancy

Parity: No. of births beyond 24 weeks

Abortion is termination before 24 weeks

EDD can be calculated by ‘Naegele’s rule’ by adding 7 days and 9 months to 1st day of Last menstrual period.

Hijri calendar - add 9 months and 15 days

Formula will be G3P1+1+1 at 8th month for a

woman who is pregnant third time, parity one

with one abortion with one live child at 8th

month of gestation.

Naegele’s rule needs to be adjusted or

recalculated in following conditions for

accuracy:

1. Irregular periods

2. Women on contraceptive pills

3. Prolonged periods

Early scan is important in estimating EDD

2. Complaints and Duration: [ chronological order ]

Pain, Vomiting, Bleeding, Discharge, Fever etc.

3. History of present illness:

Elaborate or expand each complaint in chronological order.

Explain the events happened in the hospital stay and what treatment she received.

1st Trimester

2nd Trimester

3rd Trimester

History of labor

Trimester wise History:

1st Trimester – History of Pain lower abdomen,

Bleeding per vagina, fever with chills and rigors, skin rash, intake of any drugs, radiation exposure, UTI symptoms

Any investigations like ultrasound, urine pregnancy tests and any blood tests.

History of any operations or any other trauma or interventions done.

Drug and vaccination history

Whether she is booked with any doctor, if so how many visits she has had

2nd Trimester:

History of Pain lower abdomen, Bleeding per vagina, fetal movements, symptoms of anemia, Hypertension, APH and hyperemesis

Time of Quickening: [ first perception of fetal movements ] – Primi – 18 – 20 weeks, Multi – 16-18 wk

Weight gain – [ 5 kg ]

H/O of headache, blurring of vision, edema of feet, change in the color and quantity of urine.

Any investigations like ultrasound, urine pregnancy tests and any blood tests.

Immunization history.

History of any operations or any other trauma or interventions done.

Whether she is booked with any doctor, if so how many visits she has had

History of any drugs taken

3rd Trimester –

History of Pain lower abdomen, Bleeding per vagina.

Weight gain – [ 5 kg ]

H/O of headache, blurring of vision, edema of feet, change in the color and quantity of urine.

Any investigations like ultrasound, urine pregnancy tests and any blood tests.

History of any operations or any other trauma or interventions done.

Whether she is booked with any doctor, if so how many visits she has had

History of drugs intake

If it is Postnatal case:

Labor and delivery details and postnatal period.

Gravida, parity and Abortions

Elaborate each pregnancy like date and time

of delivery

Is it full term or preterm delivery

Hospital or home delivery

Normal or cesarean delivery

Male or female baby

Weight of the baby

Any complications in the delivery

Any problems for the newborn

Duration of cycle

No. of days of flow

Regularity

LMP

EDD

Usage of oral pills, IUCDs, Barriers,

Duration and any side effects

Any history of medical illnesses like,

Tuberculosis, Diabetes, hypertension,

Epilepsy, SLE etc.

Is she on treatment

Is she following up with any physician

What type of surgery she had undergone

Any history of medical illnesses like,

Tuberculosis, Diabetes, hypertension, SLE,

Congenital anomalies, Heart diseases,

Multiple pregnancy

Chromosomal diseases and metabolic

diseases

H/O Consanguinity.

To drugs

To food

Any others

Occupation

Income or Living Status

Level of education

Total family members

AND

Smoking

Alcohol intake

Drug abuse

Sleep, Bowel habits, Diet

Look for pallor, cyanosis, jaundice, hydration status, oral hygiene.

Thyroid and any neck swellings

Breast examination:

Koilonychia, Clubbing

Edema feet, varicose veins in legs

Vital signs:

BP – in semi-recumbent position at 45 degrees

PR,RR,Temperature:

Weight in Kg:

Height in Cm:

Calculate BMI = Wt[kg]/Ht[mt square]

CNS

CVS

Respiratory System

GIT

Genitalia

Urinary system

Locomotory system

INSPECTION:

Size of abdominal distension

Symmetrical or Asymmetrical

Umbilicus – Inverted, flat or Everted

Fetal movements

Scars

Engorged veins

Hernia sites: Umbilical, Para-umbilical,

Inguinal

LINEA NIGRA: a dark pigmented line from

xiphi-sternum to symphysis pubis

STRIAE GRAVIDARUM: recent stretch marks

are purplish in color

STRIAE ALBICANS: old stretch marks look

silvery white

PALPATION:

Symphysio-fundal height: measured in centimeters

Measured from 20 weeks onwards

Estimation of no. of fetuses

If it is a single fetus –perform Leopold maneuvers:

1. Fundal height and Grip

2. Lateral or Umbilical grip

3. Superficial or Pawlic’s grip

4. Deep pelvic grip

Mrs.-------------- is a 21 year old Saudi house

wife married for 2 years Primi or G4, P3, A0

and living 3 at 33 weeks admitted with high

blood pressure for admission and further

management.

Bio-data is same

Complaints and duration –

Abnormal uterine bleeding

Infertility

Vaginal discharge

Pelvic pain

History of present illness:

Age of menarche

Duration of cycle

Amount of flow

Pain with periods – Dysmenorrhea

Premenstrual symptoms

Inter menstrual spotting or bleeding

Date of LMP

Obstetric History:

Past & Surgical History:

Family History:

Treatment History:

Allergy History:

Sexual history:

Husband

Prevention of pregnancy

Protection against STDs

Practices

Social and Personal History:

Past Gynecological history

Any previous PID, Endometriosis, fibroids, etc

Any operations

HRT

General Examination

Systemic Examination

Abdominal examination

Local or Genitalia examination

Per speculum examination

Per vaginal or Bimanual pelvic examination

Vagino-rectal examination

Provisional diagnosis

Differential diagnosis

Mrs.----------- Saudi, 17 year old, complaining

of vaginal discharge for evaluation and

management

Thank You All