History Taking In obsteric and Gynea

Question 1

What are the components of biodata

Answer 1

Name: (First name before surname)
Age
Occupation
Address
Religion and sect (If Jehovah’s witness)
Tribe
Marital status
Educational level
Parity
Last menstrual period (LMP) Expected date of delivery (EDD)
Estimated gestational age (EGA)

Question 2

2.REASON(S) FOR VISIT It maybe for

Answer 2

• Booking
• Routine ante n a t a l
• New complaint

Question 3

Ask pregnant women about the following list them

Answer 3

• How, Where, When pregnancy was confirmed
• Problems since onset of pregnancy and treatment received
  -Number of antenatal visits
  -Immunization received
  -Drugs she has been taking
  -Investigations done
• Genotype and blood group fi known
• HIV status

Question 4

Complaints to ask women

Answer 4

Any new complaint (Excessive vaginal discharge, bleeding per vaginam, fever ete and clerk as appropriate).

Question 5

PAST OBSTETRIC HISTORY (Detailed history of each pregnancy)

Answer 5

-Year of pregnancy
- Duration and outcome of
pregnancy
-Labour and puerperium
-Mode of delivery
-Length of labour
-Post partum events (Post partum haemorrhage, fever etc)
-Sex of baby and birth weight
-Days spent before discharge
-Present state of the child (alive or dead)

Question 6

GYNAECOLOGICAL HISTORY detailed

Answer 6

Age at menarche
- Length of menstrual cycle and period
Ask about history of:
.1 Menorrhagia(Heavy or prolonged periods or bleeding
i. Dyspareunia(pain during or after sexual intercourse )
iii. Dysmenorrhoea( menstrual cramps )
iv. Contraception
- Details of abortion (if any)
- Last Pap smear

Question 7

Age at menarche comprises of

Answer 7

*length of periods
*length of menstrual cycle

Question 8

PAST MEDICAL HISTORY detailed

Answer 8

Ask about history of;
-Diabetes mellitus
- Hypertension
- Respiratory diseases (Tuberculosis, Asthma)
Blood transfusion (which may cause Rhesus isoimmunization)
Previous surgery (myomectomy, VVF repair, etc)
- Drug allergies

Question 9

FAMILY HISTORY

Answer 9

• Diabetes mellitus
• Hypertension
• Twinning

Question 10

SOCIAL HISTORY

Answer 10

Type of marital status and
occupation of the husband
-Smoking of cigarettes
-Illicit drug use
-Alcohol consumption

Question 11

Drug history

Answer 11

• Drug of importance: Antihypertensives, Oral hypoglycaemics, Tetracycline, Phenytoin, Warfarin

Question 12

Systemic review

Answer 12

Head to Toe

Question 13

Summary of clerking must contains all the following list

Answer 13

Name
- Age
- Gravidity
-Parity
- EGA
- Reasons for visit
- Important findings
- Investigations done

Question 14

An example of the summary

Answer 14

I have presented Mrs S.A, a 25 year old gravida 4, para 2 one alive, EGA 22 weeks who is here for routine
antenatal visit. She complained of generalized body pain today. She has had her PCV, Urinalysis, Genotype and Blood grouping done.

Question 15

Calculation of EDD from LMP

Answer 15

Naegele’s rule (for 28 day cycle): EDD =LMP +7Days +1year -3months
Or
+7days +9months

E.g. LMP = 16/06/2024
EDD = 23/03/2025

Question 16

Estimation of gestational age:

Answer 16

• Every 3 months is 13 weeks the you count 3months till the current day to get the gestational
  LMP is 15/ Jan 2024
  Weeks thus Jan 15, Feb 15, march 15,April 15, June 15,July 15,August 15,so today sep 7 which means 1 week because and calculate those months that have 31 days if u don’t have complete 3 months