Transcript HISTORY IN OB/GY

Introduction to OB/Gyn
Rotation (481 GYN)
History Taking in OB/Gyn
D r. H a z e m A l - M a n d e e l , M . D
Assistant Professor & Consultant
Obstetrics & Gynecology
Course 481 GYN
Course Contents
 2 wks of lectures (theory part)
 Skill Lab (divided groups)
 Presentation on relevant instruments in Ob/Gyn
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(one group)
8 wks of clinical exposure + tutorials
2 wks for exams  total of 12 wks
Marks: 10 (attendance & Hx taking) + 35
(continuous exam) + 55 (final exam)
Exam parts: MCQS, Written OSCE (10 questions) +
Oral OSCE (5 stations)
Important points to remember in
History Taking
 Identify yourself to the patient & her companion
 Address the patient respectfully
 Respect the patient wishes & privacy during the
interview & examination
 Ensure cleanliness, good grooming & clothes, and
good manners in all patient encounters
 Avoid casual approach to all patients
 Maintain the privacy of the patients' medical
information & records
Main History
 Never declare patient identity in a teaching session
 Personal history: age , marital status & duration of
marriage if she is married, occupation ± nationality
 Gravidity (if she is pregnant) & Parity
 Last menstrual period (LMP)
 Present complaint(s) & duration (using the patients’
own wards)
History of Present Complaint(s)
 Start from the time of the complain and move
backward or forward
 Some patients may not have a complain as those
admitted electively (e.g. from the clinic)
 History of present problem should describe the full
details of the complain , onset, duration,
characteristics, any associated problems and
important positive & negative symptoms
 Mention any prior investigations of the problem and
any treatment(s) received
Obstetrical History
 Previous pregnancies should be reviewed in
chronologic order with the following information:
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Date (year or how many years ago) and location of delivery
Duration of gestation in weeks (if possible)
Any important problems or complications during prenatal or
antepartum course
Duration of & type of labor (spontaneous or induced)
Type of delivery (vaginal delivery, instrumental delivery such
as forceps or ventose, or cesarean section) & indication
Any maternal or fetal complications during peripartum period
Birth weight, gender and current status or any complications
How do you lay down number of
pregnancies & Abortions
 GPA system or GTPAL system
 Gravida (G) describes the total number of confirmed
pregnancies regardless of the no. of fetuses or
gestational age when the pregnancy ended
 Parity (P) describes pregnancies that continued for
> 20 wks, regardless of number of fetuses & whether
alive or stillbirth
 Abortion (A) is used for the number of abortions,
ectopic pregnancy , or molar pregnancy
Gravidity & Parity
 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
 A woman with previous live twins delivered at 34 wks, one
previous ectopic pregnancy & currently pregnant: ?
 A pregnant woman had three preterm babies at 24 wks, non is
viable is: G? P? A? (GTPAL)
 First pregnancy will call the woman primigravida
 Previous delivery(s) after 24 wks will call her
multiparous
How to calculate the expected date of
delivery (EDD /EDC)
 Use Nageles rule: add 9 months & 7 days to first day
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of LMP (or add 7 to the day and subtract 3 from the
months)
Example: LMP 4-3-2009  EDD: ?
Example: LMP 28-4-2009  EDD: ?
Remember pregnancy is 40 weeks (not 36)
Term pregnancy is completed 37 weeks of
gestation (i.e. 38 to 42 wks)
Preterm pregnancy is <37 wks
Post-term pregnancy is > 24 wks
Gynecological History
 Menstrual history (length, days of menses, amount
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of flow, regular cycle or not)
Intermenstrual bleeding or post coital bleeding
Presence of dysmenorheoa (painful menstruation)
Sexual history & dyspareunia (painful coitus)
History of contraception
Any history of lower genital tract infections
In case of infertility, you should take history about
the husband as well
Other History Parts
 Systemic Review
 Medical history: any significant medical diseases
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such as DM, HTN, etc…
Surgical history: any surgical procedures
Medications and allergies
Family history: any significant illness esp. those with
potential genetic predisposition
Social history , habits , smoking, alcohol, drugs
abuse, and socioeconomic status if possible