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    Ob Gyn Sample Hisotry

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    Sophia Rubia
    This document contains a patient's obstetrics history including: 1. The patient is a 30-year-old female, G2P1, who was admitted for labor pains. 2. Her past medical, menstrual, obstetrical, and prenatal histories are included and unremarkable. 3. Her physical examination upon admission found her in latent phase of labor and a working diagnosis of pregnancy at term with gestational diabetes and chronic hypertension.

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    Ob Gyn Sample Hisotry

    Uploaded by

    Sophia Rubia
    312 views4 pages
    This document contains a patient's obstetrics history including: 1. The patient is a 30-year-old female, G2P1, who was admitted for labor pains. 2. Her past medical, menstrual, obstetrical, and prenatal histories are included and unremarkable. 3. Her physical examination upon admission found her in latent phase of labor and a working diagnosis of pregnancy at term with gestational diabetes and chronic hypertension.

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    This document contains a patient's obstetrics history including: 1. The patient is a 30-year-old female, G2P1, who was admitted for labor pains. 2. Her past medical, menstrual, obstetrical, and prenatal histories are included and unremarkable. 3. Her physical examination upon admission found her in latent phase of labor and a working diagnosis of pregnancy at term with gestational diabetes and chronic hypertension.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    312 views4 pages

    Ob Gyn Sample Hisotry

    Uploaded by

    Sophia Rubia
    This document contains a patient's obstetrics history including: 1. The patient is a 30-year-old female, G2P1, who was admitted for labor pains. 2. Her past medical, menstrual, obstetrical, and prenatal histories are included and unremarkable. 3. Her physical examination upon admission found her in latent phase of labor and a working diagnosis of pregnancy at term with gestational diabetes and chronic hypertension.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    The document provides an obstetric history and physical examination of a 30-year old female patient who presented with labor pain.

    The patient has no significant past medical history and no known allergies. Her family history is notable for hypertension on both the maternal and paternal sides.

    The patient's obstetric history includes one prior full term vaginal delivery. Her prenatal history for the current pregnancy is unremarkable. She received regular prenatal care and her laboratory tests were normal.

    SAMPLE ONLY

    OBSTETRICS HISTORY
    Informant: Student’s Name:
    Reliability: Date:

    GENERAL DATA:
    N.J., 30 years old, female, G2P1(1001), married, Roman Catholic, office worker, born on
    March 12, 1989, from Camotes Island, Cebu and currently residing in Mabolo, Cebu City, was
    admitted for the second time at Cebu Maternity Hospital on _______ due to labor pain.

    PAST MEDICAL HISTORY:


    Patient is non- hypertensive, non-diabetic and non-asthmatic; no food nor drug
    allergies. She is a non-smoker, non-alcoholic beverage drinker and no history of illicit drug use.
    Heredofamilial disease includes hypertension, both on maternal and paternal side. Birth rank
    1/5. Childhood illnesses include Varicella and Rubeola. Childhood and adult immunization
    unrecalled. Previous hospitalization is for obstetric reason.

    MENSTRUAL HISTORY:
    Menarche was at 12 years old which lasted for 3 days, light blood flow, used up 2-3
    sanitary pads per day, no dysmenorrhea. Her subsequent menstrual periods were of regular
    monthly interval 30 +/- 5 days, usually lasting for 3 days moderate blood flow using up 2-3 fully-
    soaked sanitary pads per day. No dysmenorrhea, no intermenstrual bleeding, no amenorrhea.
    Coitarche was at 25 years old and claimed to have 2 sexual partners. Patient did not use any
    kind of contraception.

    OBSTETRICAL HISTORY:
    G2P1 (1001)
     G1- 2015, Full Term, Delivered via NSD, Female, 2.5 kgs, Alive, Cebu
    Maternity Hospital, No complications
     G2
    o LMP=
    o PMP=
    o EDC=
    o AOG=
    PRENATAL HISTORY:
    First prenatal consultation at 19 weeks AOG at Cebu Maternity Hospital -OPD. Regular
    PNC thereafter. Laboratory tests include: CBC, Urinalysis, Blood Typing, HIV, HbsAg, FBS, 75g
    OGTT, results were unremarkable. Medications include Folic Acid, Ferrous Sulfate and Calcium
    Carbonate taken once daily. She received Tetanus Toxoid Vaccine at 22 weeks AOG at CMH-
    OPD. Her usual blood pressure was 100-110/60-80 mmHg. Weight gained during pregnancy was
    25 lbs. No maternal illnesses incurred during the entire course of pregnancy.
    CHIEF COMPLAINT:
    Labor pain
    HISTORY OF PRESENT ILLNESS:
    Two hours prior to admission, patient had onset of mild to moderate, on and off
    hypogastric pain, relieved with rest. Thirty minutes PTA, labor pain became more severe with
    intervals of 4-5 minutes, radiating to the back, not relived with rest. No bloody nor watery
    vaginal discharges, (+) Good fetal movement, (-) febrile episodes, no nausea and vomiting.
    Condition persisted, hence patient sought consult and was subsequently admitted.
    PHYSICAL EXAMINATION:
     GENERAL SURVEY - Patient examined on bed, awake, alert, coherent, cooperative and
    not in respiratory distress.
     Vital Signs
     Blood Pressure – 120/80 mmHg right arm supine
     Temperature – 36.8 C
     RR – 17 cpm
     HR – 89 bpm
     O2 saturation – 99 %
     Weight – 51.5 kgs
     Height – 5’2”
     Skin – warm to touch, good turgor, no rashes, no lesions
     HEENT – normocephalic, anicteric sclerae, pink palpebral conjunctiva
     Neck – supple, no masses, no lymphadenopathy, no jugular vein distension
     Breast-
     Chest and Lungs – Equal chest expansion, clear breath sounds, no rales, no wheezes
     CVS – normal rate, regular rhythm, distinct S1 and S2 heart sounds, no murmur
     Abdomen. -globular, (+) linea negra and striae gravidarum, no surgical scars, with
    uterine contractions every 4-5 minutes interval and 40 -50 seconds duration, moderate
    intensity,ps
     Fundic Height – 31 cm
     FHT – 145 bpm RLQ
     EFW – fh-12x155= ____ grams
     Leopold’s Manuever – L1 – breech, L2 – Fetal back: maternal left, Fetal
    small parts: maternal right, L3 – cephalic, engaged, L4 - flexed
     GUT – BPE
     Introitus – parous
     Cervix – 3 cm dilated, 70% effaced, station -3, cephalic, intact bag of
    water
     Uterus – enlarged to AOG
     Adnexa – not delineated
     Discharges - negative
     CNS - DTR +2
     Extremeties – strong pulses, grade 1 non-pitting bipedal edema, no varicosities
    WORKING DIAGNOSIS:
    1. G2P1 (1001) Pregnancy Uterine ____ weeks AOG by UTZ/LMP, ( ) presentation, in
    latent phase of labor
    2. Gestational DM, Diet Controlled
    3. Chronic Hypertension
    4. S/P Appendectomy, 2016

    FOR GYNECOLOGIC PATIENTS: TAKE SPECIAL ATTENTION TO THE FOLLOWING IMPORTANT


    DETAILS IN GETTING THE HISTORY AND P.E.

     General Data:
     Menstrual History
     Menarche, duration, flow and cycle length of menses, intermenstrual
    bleeding or contact bleeding, dysmenorrhea, PMS,climacteric
     Obstetric History:
     Gynecologic History: Breast history = history of breast disease, breastfeeding, the use of
    Self Breast Exam, last mammogram ; previous gyne surgery, history of infertility, last
    pap smear – history of abnormal papsmear result
     Contraceptive/ Sexual History
     Current methods/ patients satisfaction with current method
     Past method
     Current sexual active
     Number of partners , new partner in the last 3 months
     Condom use
     History of sexual abuse
     Past Medical History
     Previous Operations/ Blood Transfusions
     Allergies
     Medications
     Infectious diseases (gonorrhea, syphilis, herpes, HIV, TB, hepatitis)
     Medical Illness
     Personal and social history
     Marital status, employment
     Habits (smoking, alcohol, drug use)
     Family history:
     CHIEF COMPLAINT:
     HPI:
     Pertinent negatives may include, abnormal discharge, abnormal bleeding,
    dyspareunia, abdominal/ pelvic pain, dysuria, urgency, incontinence,
    change in bowel habits, rectal bleeding
     For post/perimenopausal woman – hot flashes/ night sweats, vaginal
    dryness, abnormal bleeding, irritability, depression, mood changes
     Physical Examination
    o General Survey
    o SaME as OB PE
    o BPE : ICUAD
    o Recto-vaginal exam
     Working Diagnosis
     Plan / Intervention

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