Gynaecological history

Particulars of the Patient: Date of admission: Name:

Date of examination:
Age: Bed no.:
Religion: Reg. no.:
Occupation: Name of Hospital:
Address: Present: Permanent:

C hief C omplaints: According to duration & severity of disease.

History of Present Illness:

Menstrual History:
Age at menarchae:
Menstrual period (duration): 4~5 days
Menstrual cycle: 282 days
L. M. P (Last Menstrual Period):
Dysmenorrhoea:

Obstetric History:
Married for:
Para:
Mode of delivery:
Abortion/ MR:
Age of last child:

History of Past Illness:

Family History:

Personal History:

C ontraceptive History:

Drug History:

Socio-economic History:
General Examination:
Appearance: Pulse:
Body built: BP:
Anaemia: Temperature:
Jaundice: Respiratory rate:
Edema: Heart/ Lungs:
Dehydration: Thyroid gland:

Breast Examination:

Per-abdominal examination:
Inspection:
Palpation:
Percussion:
Auscultation:
Before abdominal examination, ask the patient to empty her bladder. (Ref.: Prof. Khaleda Madam)

Pelvic Examination:
Per vaginal Examination: Inspection (naked eye & per- speculum)
Per rectal:

Salient Features: Short history, positive findings, important negative findings.

Provisional Diagnosis:

D/D:

Investigations:

C linical Diagnosis:

Management: General/ Specific

Advice on discharge:

Follow up & outcome:

 Obstetrical history
Particulars of the Patient: Date of admission:

name Date of examination:

Age: Bed no.:
Religion: Reg. no.:
Occupation: Name of Hospital:
Address: Present: Permanent:

C hief C omplaints: According to duration & severity of disease.

History of Present Illness:

Obstetric History:
Married for:
Para:
Mode of delivery:
Abortion/ MR:
Age of last child:
Obstetrical C hart:
No. Y ear of Duration ANC Complication Mode Complicatio Puerperiu Infant-
Pregnanc of of pregnancy & place n during m- Alive/dead
y pregnanc of delivery normal/ Wt. & sex
y deliver abnormal Congenital
y anomalies
Breast
feeding

Menstrual History:
Age at menarchae:
Menstrual period (duration): 4~5 days
Menstrual cycle: 282 days
L. M. P (Last Menstrual Period):
Dysmenorrhoea:
History of Past Illness:

Family History:
Personal History:

C ontraceptive History:

Drug History:

Immunization History:

Socio-economic History:

General Examination:
Appearance: Pulse:
Body built: BP:
Anaemia: Temperature:
Jaundice: Respiratory rate:
Edema: Heart/ Lungs:
Dehydration: Thyroid gland:
Breast Examination:
Per-abdominal Examination:
Inspection:
Palpation:
Symphysio-fundal height:
Abdominal grip:
Fundal grip:
1st pelvic grip:
2nd pelvic grip:
Foetal movement:
Percussion:
Auscultation: FHR
Before abdominal examination, ask the patient to empty her bladder. (Ref.: Prof. Khaleda Madam)

Pelvic Examination:
Per vaginal Examination:
Cervix (dilatation & effacement):
Presentation:
Station:
Membrane: ruptured/ intact
Colour of liquor:
Pelvis: adequate/ not
 Puerperium: Lochia (colour, amount, odour etc.)

Examination of the baby:

Age, Sex:
Anthropometric measurement: length, weight, occipito-frontal measurement, anterior
fontanalle.
Colour, jaundice:
Feeding, dehydration:
Umbilicus:
Bladder, bowel, genitalia:
Congenital anomalies:
Heart rate:
Respiratory rate:
Reflex: Suckling reflex, Moro reflex, Rooting reflex

Salient Features: Short history, positive findings and important negative findings.

C linical Diagnosis:
Primigravida at 37 weeks of pregnancy with labour pain
Or
2nd gravida at 37 weeks of pregnancy with pre-eclampsia
Or
1 day normal puerperium following normal vaginal delivery with episiotomy/ LUCS
st

(Lower Uterine Caesarean Section) due to foetal distress.

Investigations:
Antenatal case: Hb%, Urine R/M/E, RBS, Blood grouping & Rh-typing, USG.
For normal puerperium: Hb%, Urine R/M/E,
For abnormal puerperium

Management:
Advice on discharge
Post-natal visit: after 07~08 weeks (for normal delivery)
after 02 weeks & 06 weeks (for C/S).