History
History
C/C :
HPP or HPI :
-current pregnancy :
The pt. was diagnosed to be pregnant after she missing her period for ( ) wks by
(blood (2wks) urine (5wks) ) tests which done in ( / / ) . She gave Hx of (N/V/
hyperemesis gravidarum) in early wks for about….
ANC (regular, where, when start, last visit, complication )
U/S ( 1st US done(16-20wks), where, when, result, other US )
Fetal movement (1st one notice at (16-20 wks), regularity, continuous.
Medications (folic acid , iron , vitamins , OCPs , other )
Weight gaining(10-15Kg)& blood glucose screening(24-28wk)
Hx of ( DM , HTN ,UTI ,Vaginal bleeding or discharge , fever)
-current complain:
pain: Site, radiation, Nature, Relation to periods, Aggravating and relieving factors,
associated SS
Vaginal discharge: amount, color, odor, blood, rash, pain
Micturation and bowel: Frequency of micturation increase, incontinence (real or
stress), urgency, dysurea, hematurea, Loin to groin pain
Investigation done to her (BSP, Hb , Bp , US , X- ray …)
Risk factor
Menstrual History
Menarche: (age , cycle days/ interval from first day to first day of next period,
duration of bleeding, regularity, normal amount, No. of tampons or pads staining
use , dysmenorrhea (1ry or 2ry), intermenstrual bleeding, post coital bleeding,
dyspareunia, Contraception ( IUCD, condoms, OCP…)
Obstetric history:
age & FT or NSVD Wt. PP- Where Breast Alive ANC Nursery
sex PT& assisted complc &anast Feed or died DM
GA C/S ation hesia or not HTN
G1
G2
Social history:
House wife or working mother(load heavy or not ), education, living status,
socioeconomic state, smoker, alcoholic, habits, her husband (work, old, health,
relation b/w her & her husband, relativity )
How long she married ?
Drug and allergy history: OCP, induce ovulation & Teratogenic drugs .
Systemic review :
Summary :