O & G History Taking

Question 1

OSCE

Introduction

Answer 1

1. GREETING AND INTRO
   2.PURPOSE AND CONSENT

Question 2

3. DEMOGRAPHICS

Answer 2

3. DEMOGRAPHICS
   • Name
   • Age
   • Marital status
   • Occupation
   • Religion
   • Address
   • Insurance
   4.REPRODUCTIVE PROFILE
   • Currently pregnant?
   • LMP
   • EDD
   • EGA
   • Gravidity
   • Parity

Question 3

PC

HPC

Answer 3

5. PRESENTING COMPLAINT + DURATION

6.HISTORY OF PC
• Chronology of complaints
• What has been done
• Additional concerns

Question 4

DIRECT QUESTIONING

Answer 4

DIRECT QUESTIONING
• Question affected system.
• Danger signs of pregnancy (headaches, vomiting, smelling discharge, loss of liquor, bleeding per
vagina, fetal movements)

Question 5

Systemic review

Answer 5

8.SYSTEMS REVIEW
• Respiratory
• Cardiovascular
• CNS
• GIT
• Musculoskeletal
• Genitourinary

Question 6

Drug history

Past medical and surgical history

Answer 6

DRUG HISTORY AND ALLERGIES
• Current medications
• Herbal medications
• Drug allergies
• Food allergies
10. PAST SURGICAL AND MEDICAL HISTORY.
• THREDS
• Admissions
• Surgeries
• Transfusion

Answer 7

11.FAMILY HISTORY
• THREDS
• Hx of fibroids
• Hx of multiple pregnancy 🤰

Question 8

12. Past obstetrics history

Answer 8

12. PAST OBS HISTORY

A. INDEX PREGNANCY • Method of finding out
• Intentions
• Booking visit
• Blood pressure at visit
• Other assessments at visit
• Scans (when, how many,
outcomes)
• Malaria prophylaxis
• Tetanus injection
• Haematinics
B. PREVIOUS PREGNANCIES
• Number of pregnancies
• Duration and outcomes
• Place of delivery
• Method of delivery
• Sex of baby
• Cry at birth
• Exclusive breastfeeding
• Any maternal complications

Question 9

13. GYNAE HISTORY MENSTRUAL HISTORY

Answer 9

13. GYNAE HISTORY MENSTRUAL HISTORY
    • Menarche
    • Length of cycle
    • Regularity
    • Flow length
    • Flow volume
    • Dysmerrohea
    SEXUAL HISTORY • Coitache
    • Number of sexual partners
    • Dyspareunia
    • Bleeding after sex
    CONTRACEPTIVE HISTORY
    • Usage
    • Method
    • Duration of usage
    • Any associated issues
    STIs HISTORY
    • Any discharges
    • Lower abdominal pain
    • Any previous diagnosis
    • Any previous treatment
    SCREENING HISTORY
    • Pap smear
    • Breast screening

Question 10

Social history

Answer 10

14.SOCIAL HISTORY • Marital setting
• Husbands’ occupation
• Alcohol intake
• Smoking
• Recreational drugs
• Others

Question 11

SUMMARY