Obstetrics and Gynecology History

ID

  • Name
  • Age
  • Occupation
  • Gravida/Parity
  • Gestational Age
  • Estimated Due Date
  • Blood types
  • GBS screen

CC or Reason for Referral

  • Regular visit
  • Gyne visit: Bleeding, Pain, Mass, Discharge, Infection
  • Caseroom: Pain/?Labor, Bleeding, No baby movement, ?Ruptured membranes, Dysuria

HPI

  • OLDSCARS: Onset, Location, Duration, Severity, Character, Alleviating/Aggravating factors, Radiation, Symptoms associated
  • Associated symptoms
    • Gynecologic: bleeding, pain, mass, discharge, infection, dysuria
    • Caseroom: contractions (regular, painful, length, predictable, frequency, strength), bleeding, baby movement, ruptured membranes (with cough? How much flow?), dysuria
    • PIH: headache, visual changes, epigastric pain, N/V
    • Bleeding: how much, how long, from where, associated pain, contractions, previous imaging (previa)
  • Last meal (if for surgery)

PREGNANCY HISTORY

  • How did she find out she was pregnant
  • LNMP, EDD
  • Antenatal care?
  • Any complications? bleeding, infection, hypertension, diabetes
  • Investigations thus far and findings? ultrasound, amnio, NST, BPP, blood glucose, GBS, blood type
  • Trimester
    • First: N/V, bleeding, ANC, EtOH/Rx use
    • Second: quickening, scan for dates, amniocentesis
    • Third: fetal movements, weight gain, edema, contractions



 

PAST PREGNANCY HISTORY

  • Gravida, Term, Premature, Abortions, Live
  • Other pregnancies’ dates, hospital, duration of labor, method of delivery, result (gender, apgars)
  • Complications – antenatal, intrapartum, postnatal

GYNECOLOGIC HISTORY

  • Menstrual history
    • Menarche, Cycle, Nature of periods, Regularity, LNMP, Dysmenorrhea, PMS, Postcoital and intermenstrual bleeding, Menopause, Postmenopausal bleeding
  • Contraception
    • Current method, Adherence, Previous methods, Planned pregnancy
  • Vaginal discharge
  • Urinary history
    • Frequency, Dysuria, Urgency of micturition, Stress/Urge incontinence
  • Pap smears
  • Sexual history
    • Frequency, Dyspareunia, Number of partners
  • Infectious history
    • Swabs, STIs, Yeast infections, Sexual activity
  • Gyne surgeries or other interventions/investigations

Past Medical History – CVS, Respiratory, Neuro, Endocrine, MSK, GI, GU

Past Surgical History – C-sections, D&C, cervical surgery, biopsies?

Family History

SOCIAL HISTORY – smoking, EtOH, street drugs, current living situation, job, relationship, Hx/current abuse

MEDICATIONS – vitamins, any stopped during pregnancy or taken before knew of pregnancy

ALLERGIES – note reaction

ROS

INVESTIGATIONS

  • Specialist consultations
  • Ultrasounds – dates, place, findings
  • Bloodwork – when, where, results
  • Specific screens
    • 10-14 weeks
      • First trimester combined screening for Trisomy 21
      • Nuchal Translucency UltraSound (NTUS)
      • Serum β hCG
      • Pregnancy associated plasma protein A (PAPP-A)
    • 14-18 weeks
      • Fetal movement (quickening)
    • 15 – term
      • Amniocentesis
    • 16 weeks
      • Maternal Serum Screen for Trisomy 21 and oNTD
      • Maternal serum α-fetoprotein (MSAFP)
      • Serum β hCG
      • Unconjugated estrogen (estriol or uE3)
MSAFP β hCG uE3
oNTD
Trisomy 21
Trisomy 18
    • 16-20 weeks
      • Ultrasound for dates, structural assessment
    • 24-28 weeks
      • 50g Oral glucose challenge
    • 28 weeks
      • CBC, RhIG for all Rh negative women
    • 36 weeks
      • GBS screen, Rh antibody screen if indicated

OBSTETRIC EXAMINATION

General and Vitals

            HEENT

CVS

Respiratory

Neurological – especially in PIH (CN, tone, reflexes, clonus)

Abdominal

  • Inspection
    • Scars, Linea nigra, Distension, State of umbilicus, Striae, Fetal movement
  • Palpation
    • FSH
    • Uterine tone and tenderness
    • Lie, presentation, position, attitude
  • Auscultation
    • Fetal heart beat via doppler

Pelvic

  • Cervical changes
    • Position
    • Consistency
    • Effacement
    • Dilatation
    • Station
  • Speculum – nitrazine swab (blood, semen, urine, amniotic fluid)

GYNECOLOGIC EXAMINATION

General and Vitals

Pelvic

  • Inspection
    • Hair distribution, Vulval inflammation/infection, Scars
    • Vaginal discharge, Odour
    • Incontinence of urine on coughing, Prolapse
  • Bimanual
    • Cervix: consistency, regularity, excitation, pain, position
    • Uterus: size, shape, consistency, mobility, pain
    • Adnexae: palpable, size, pain, masses
  • Speculum
    • Cervix:      inflammation, Nabothian follicles, eversion, polyps
    • Vagina :     estrogenization, urethral dislocation, bladder neck support, cystocele, rectocele, enterocele
    • Pap smear
    • Swabs for Chlamydia and Gonorrhea

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