Obstetrics and Gynaecology Hx Taking Notes PDF

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Obstetrics and Gynaecology Hx Taking Notes...

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Obstetric and Gynaecological History Taking Template

1. Introduction - Name, date of birth 2. Presenting Complaint 3. History of Presenting Complaint Present Pregnancy

a. 1st trimester (1 - 12) - booking clinic checkup, symptoms eg nausea vomitting, b. 2nd trimester (13 - 26) - 20 week anomaly scan, c. 3rd trimester (27 to end of pregnancy) - blood pressure (signs of oedema, headaches), fetal movement / growth

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Vaginal bleeding Vaginal discharge Urinary symptoms Headache, visual changes,

4. Background (MOSC) A. Menstrual History - LMP - Age of menarche / age of menopause - Duration and regularity - Menstrual flow - light / heavy - Menstrual pain - Post coital bleeding - Inter-menstrual bleeding - Dysparaunia (superficial / deep) B. Obstetric History (to establish gravity and parity) - Current and past: Date, antenatal, intrapartum and postpartum complications, delivery method - Miscarriages - Terminations

- Ectopic pregnancies C. Sexual History - Number of partners - STD screening / diagnosis D. Contraception + Cervical Smear - Type, duration - Date and results of pap smear - Previous gynaecological conditions and treatments

5. Others a. b. c. d.

Past Medical / Surgical Hx Family Hx Drug Hx Social Hx

4. Summary a. Diagnosis b. Investigations c. Management plans...