OB/GYNE History Taking Protocol
| Component | Key Points to Cover |
|---|---|
| Identification & Demographics | - Patient: Name, age (note implications for treatment, e.g., ≥37 y.o. for IVF), occupation (note exposures: radiation, night shifts), tribe/nationality, residence, blood group. - Husband: Name, age (>50 linked to mutation risks), occupation (e.g., driver, farmer, work abroad affecting infertility), consanguinity, blood group. - Marital: Date of marriage (duration), history of prior children (especially in cases of infertility). - Date of first examination. |
| Chief Complaint (C/O) | - Document the primary reason for the visit (e.g., bleeding, discharge, abdominal pain). |
| History of Presenting Illness (HPI) | - Use a structured approach (e.g., SOCRATES/OPERATES;non pain) to detail the chief complaint.m then systemic review, i suggest starting with obs and gyn history before HPI - Include a targeted systemic review as relevant to the complaint. |
| Obstetrical History | - Summary: Gravidity, Parity, Losses. - Current Status: Last Menstrual Period (LMP), Estimated Date of Delivery (EDD), Gestational Age (GA by LMP or US). - Past Pregnancies: *For each pregnancy, detail the following: * - Duration of pregnancy and any antenatal complications. - Labour: Duration, method (e.g., SVD, C-section), and complications (e.g., Postpartum Hemorrhage - PPH). - Infant: Birth weight, sex, and current status (age, alive and well?). - Puerperium: Any complications (e.g., infection, thrombosis). - Losses: Note GA for each, fate (e.g., evacuated or not), need for blood transfusion (BT), and any histopathology results. |
| Current Pregnancy Details if pregnant | - 1st Trimester: Folic acid use, teratogen exposure, Nausea and Vomiting (NVP), dating scan, Down’s syndrome screening. - 2nd Trimester: Quickening (~18-20 wks for primigravida, ~16-18 wks for multigravida), vaccinations, anomaly scan, iron supplementation. - 3rd Trimester: Fetal movements, assessment scans, discussion of delivery mode, counseling on puerperium & breastfeeding. - In all Trimesters: Systematically ask about bleeding, UTI symptoms, and signs of anemia. |
| Gynaecological History | - Menstrual Cycle: Menarche (late menarche can indicate early menopause), regularity, amount, duration, dysmenorrhoea (may suggest endometriosis, infection), Intermenstrual Bleeding (IMB), Post-Coital Bleeding (PCB, common cause is polyps). - Vaginal Discharge: Color, odor, itching. - Screening & Procedures: Cervical smear history (last date, result, management), past gynaecological operations (e.g., ovariectomy). - Contraception: Type used prior to conception, duration of use, side effects, when it was stopped. - Conditions: History of polyps, endometriosis, PCOS, cancer. - Conception: History of assisted conception methods (e.g., IVF). |
| Paternal History | - Note any relevant surgical history (vasectomy), trauma, testicular varices, or previous semen analysis results. |
| Past Medical & Surgical History | - Medical: Chronic conditions (DM, HTN, Asthma, Renal/Heart disease), prior hospital admissions, history of blood transfusions. - Surgical: History of procedures like appendectomy, cerclage, Dilation and Curettage (D&C). |
| Family & Social History | - Family: History of recurrent abortions, congenital anomalies, or gestational diabetes in relatives. - Drug History: Current and past medications, known teratogens, allergies. - Social History: Smoking, alcohol or drug abuse, available social support systems. |
| Summary | - Conclude the history taking with a concise summary of the key findings. |