Obs & Gyn - Sample History

[ACCM]

Here you can find sample history in Obs & Gyn.

You can also submit sample history, some of the selected histories will be published in the next edition with the acknowledgement.

[ACCM]

History

Particulars

Name: Mrs. Adhikari
Age: 25 years
Sex: Female
Religion: Hindu
Education: Bachelor
Occupation: Housewife
Marital Status: Married for 2 years
Husband’s Name: Mr. S. Adhikari
Education: Bachelor
Occupation: Doctor
Address:-
• Temporary: Sinamangal
• Permanent: Dolkha
Date of admission: 31/10/06
Mode of admission: Emergency
Date of examination: 31/10/06
LMP: 24/01/06

Chief Complaints
• 5th post operative day of caesarean section
• Pain at the lower abdominal wound site – 5 days

History of Present Illness
According to the patient, this is the fifth day after emergency caesarean section due to non-progressive labour at home. Her pregnancy duration was uneventful and she had regular Antenatal checkups. She delivered a healthy female baby of 3.1 kg.
She gives the history of yellowish discharge per vagina, of about 50 ml, which was not foul smelling. There is no history of fever, burning micturation, difficulty in breast feeding.
Pain:
• Site: Lower abdomen
• Duration: Five days
• Severity: Mild
• Character: Stabbing
• Aggravating factors: Movement
• Relieving factor: Rest
• Associated symptoms: Absent
She has normal bowel and bladder habits and has no difficulty in breast feeding.

Menstrual History
K=15 x {(3 - 6 days)/(28 ± 5 days)**
• No dysmenorrhoea
• No contraceptive history
• LMP: 24/01/06

Obstetric History
• Married for - 14mths.
• P1

Obstetric note:
SN Date Pregnancy events Labor events Method of Delivery Puerperium Baby - Alive or Dead, Weight, Sex, Apgar Score, Congenital Abnormality, Breast Feeding and Immunization.
1. 26/10/06 uneventful Non-progressive CS Lower abdominal pain Alive, 3.1 kg, Male, Apgar score 5 & 9 at 0 and 5 min, no congenital abnormality, breastfed after 1 hr, BCG given

Baby note
• Sex - male
• Weight - 3.1 kg
• Skin color - normal
• Dehydration - absent
• Umbilicus - healthy
• Congenital anomaly - absent

Contraceptive History
• Use of Nilokon White for 8 months. No complaints during the use.

Past History
No history of Hypertension, Diabetes Mellitus, Asthma, Tuberculosis, Blood Transfusion. No history of past Surgeries.

Personal History
She has normal Bowel, Appetite, Sleep and Urination. She doesn’t consume alcohol, drugs, is a non-smoker and is non-vegetarian.

Family History
No history of Diabetes Mellitus, Hypertension, Tuberculosis, Abortion, multiple birth, Cancer of the Cervix, Breast cancer & Congenital abnormalities in the family.

Socioeconomic History
She is a housewife, there are five members in the family, joint family with good housing condition and safe drinking water, toilet facility is present and the family falls in the middle class group.

Drug & Allergy History
No known history of allergy to drugs, dust and food and not taking any medication.

Clinical examination
A. General Examination
1. General Characteristics
• Appearance : Well looking
• Body built : Well built
• Consciousness : Conscious
• Co-operation : Cooperative
• Decubitus : Supine
• Nutritional status is good.

Pallor – Not present
Icterus – Not present
Lymphadenopathy – Not present
Leuconychia – Not present
Clubbing – Not present
Cyanosis – Not present
Oedema – Not present
Dehydration – Hydration is good.

2. Vitals
Pulse : 72/min
Temperature : 98 F
Blood pressure : 120/80 mm of Hg
Respiration : 16/min
JVP : Not raised

B. Systemic Examination
Abdominal Examination

Inspection
• Shape is scaphoid
• There is dressing over the wound in supra-pubic region, which is not soaked.
• All the quadrants move with respiration.
• No Scar marks.
• Umbilicus is centrally placed and inverted.

Palpation
• Abdomen is soft
• Non-tender
• Wound area is mildly tender. Wound is healthy.
• Uterus is of 16 weeks size.

Auscultation
• Normal bowel sound heard.

Vaginal examination
Inspection- pad is soaked, yellowish in color & there is no foul smell.

Respiratory System: Bilateral vesicular sound heard, no added sound.
Cardiovascular System: First and second heart sound heard no murmur heard.
Central Nervous System: Intact

Provisional Diagnosis
5th post operative day of Caesarean Section
Differential Diagnosis

Investigation
• Blood: TC, DC, Hemoglobin%
• Urine: Routine and Microscopic Examination
• Stool: Routine and Microscopic Examination

Final Diagnosis

Management

Source: Angel's CONCISE CLINICAL METHODS

[Sanju]

Particulars
Name: Mrs. Laxmi Bohora
Age: 20 years
Sex: Female
Religion: Hindu
Education: SLC
Occupation: Housewife
Marital Status: Married for 12 months
Husband’s Name: Mr. Navaraj Bohora
Education: Primary
Occupation: Bar-tender
Address: Jorpati, Kathmandu
Date of admission: 02/06/2063
Mode of admission: Emergency
Date of examination: 03/06/2063
LMP: 28/08/2062
EDD: 05/06/2063

Chief Complaints:
·Cessation of menstruation since last 39 weeks + 5 days
·Pain in lower abdomen for 12 hours
·Pervaginal discharge for 12 hours

History of Present Illness
According to the patient, she is amenorrhic since last 39 wks + 5days. She confirmed her pregnancy by urine test at 4th week of pregnancy. She was admitted to KMCTH through emergency with complain of pain in lower abdomen for 12 hours, sudden onset, severe, spasmodic, radiating towards thigh, associated with hardening of uterus, was progressive, aggravated by walking, lying down with no relieving factor. She also had vaginal discharge for 12 hours which was whitish, non-copious, non-foul smelling, non-blood stained. She also had increased frequency of micturition.
She had no history of fever, dysuria, nausea, vomiting.
Events in 1st trimester
·Amenorrhoea, confirmed her pregnancy by UPT at 4th week of POG.
·Nausea
·Vomiting (medication taken)
·Loss of appetite
·Folic acid supplementation.
·Regular ANC visits.
·Normal weight gain.
·Breast discomfort
·Increased frequency of micturation
·No PV bleeding/ vaginal discharge.
·No history of fever, burning micturation

2nd trimester
·Amenorrhoea continued
·Supplementation continued.
·Quickening felt in 20th – 22nd week of pregnancy
·Tetanus toxoid, Calcium and Iron tablets taken.
·No history of leg swelling
·Normal weight gain

3rd trimester
·Amenorrhoea continued
·Fever (102°F – Influenza)
·Complained of less fetal movement on 35th weeks of gestation
·Frequency of micturation increased
·Normal weight gain
·Lower back pain since 12 hours

Menstrual History
K=12 x {(3 - 4 days)/(28 ± 5 days)**
·Dysmenorrhoea in first 2 days of cycle.
·Number of pads used: 3 pads fully soaked
·Fresh blood with clots
·LMP: 28/08/2062
·EDD: 05/06/2063
·Period of Gestation: 39 weeks + 5 days

Obstetric History
·G1 at 39 weeks + 5 days of POG
·Age at marriage 19 yrs.
·Married for 12 months
·Age at first pregnancy: 20 years
·POG: 39 weeks + 5 days

Contraceptive History
·No history of use of contraception.

Past History
No history of hypertension, diabetes mellitus, asthma, tuberculosis, blood transfusion. No history of past surgeries.

Personal History
She has normal bowel habit, good appetite, sound sleep and no urinary complaints. She doesn’t consume alcohol, drugs, is a non-smoker and is non-vegetarian.

Family History
No history of Diabetes Mellitus, Hypertension, Tuberculosis, Abortion, multiple birth, Cancer of the Cervix, Breast cancer & Congenital abnormalities in the family.

Socioeconomic History
She is a housewife, there are five members in the family, joint family with good housing condition and safe drinking water, toilet facility is present and the family falls in the middle class family.

Drug & Allergy History
No known history of allergy to drugs, dust and food and not taking any medication.

Clinical Examination
A. General Examination
1. General Characteristics
·Appearance : Well looking
·Body built : Well built
·Consciousness : Conscious
·Co-operation : Cooperative
·Decubitus : Sitting
·Nutritional status is good.
Pallor – Not present
Icterus – Not present
Lymphadenopathy – Not present
Leuconychia – Not present
Clubbing – Not present
Cyanosis – Not present
Oedema – Mild oedema present on the lower limb
Dehydration – Hydration status is good.
2. Vitals
Pulse: 90/min, Regular in rhythm, Normal in volume and character, No radio-radial and radio-femoral delay, Condition of arterial wall is normal and all peripheral pulses are palpable.
Temperature: 98ºF
Blood pressure: 130/80 mm of Hg in the right arm in sitting position.
Respiration: 20/min in sitting position, normal in depth and thoraco-abdominal in nature.
JVP: Not raised

B. Obstetric Examination
Abdominal Examination
Inspection
·Distended abdomen
·All the quadrants move with respiration.
·No Scar marks.
·Umbilicus is centrally placed and everted.
·Linea nigra and striae present
·Striae gravidarum and linea nigra present
Palpation
·Uterine shape is spherical
·Fundal height corresponds to the junction of upper and middle third of the distance between the umbilicus and ensiform cartilage.
·Head of the fetus is engaged.
·Palpable fetal movements.
·Left lateral palpation: smooth curve felt
·Right lateral palpation: nodular
·Pelvic grip
-First pelvic grip: Divergent
-Second pelvic grip: Head of the fetus engaged
Auscultation
·Fetal heart sound heard: 140/min

Vaginal examination
Inspection- whitish vaginal discharge, copious and no foul smell.
Respiratory System: Bilateral vesicular sound heard, no added sound.
Cardiovascular System: First and second heart sound heard no murmur.
Central Nervous System: Intact
Provisional Diagnosis
20 years primigravida at 39 weeks + 5 days of pregnancy with onset of labor.

Differential Diagnosis
·Pseudocyesis
·Cystic ovarian tumor
·Fibroids
·Encysted peritonitis
·Distended urinary bladder

Investigations
·Blood: TC, DC, Hemoglobin%, ESR, Blood Grouping and Rh typing, VDRL, Blood glucose, HBs Ag
·Urine: Routine and Microscopic examination (RME)
·Imaging: USG

Final Diagnosis
20 years primigravida at 39 weeks + 5 days of pregnancy with onset of labor.
Management

[Suvash]

Hey ujnas, thats a great job! that will be very useful to all of us! thanks a lot!

[Sarensa]

Thankx guys for the history keep this good work on.

[chetnarayan]

great job!