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    History Taking Form in Gynecology Obstetrics - Compress

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    keight
    The patient presented with complaints of pain and bleeding. Their medical history included one prior pregnancy and no significant past medical or surgical history. A physical exam and review of systems found bleeding, abdominal pain, and fatigue. The chief complaint, history of present illness, past medical and obstetric history, review of systems, and physical exam were documented.

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    History Taking Form in Gynecology Obstetrics - Compress

    Uploaded by

    keight
    128 views8 pages
    The patient presented with complaints of pain and bleeding. Their medical history included one prior pregnancy and no significant past medical or surgical history. A physical exam and review of systems found bleeding, abdominal pain, and fatigue. The chief complaint, history of present illness, past medical and obstetric history, review of systems, and physical exam were documented.

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    The patient presented with complaints of pain and bleeding. Their medical history included one prior pregnancy and no significant past medical or surgical history. A physical exam and review of systems found bleeding, abdominal pain, and fatigue. The chief complaint, history of present illness, past medical and obstetric history, review of systems, and physical exam were documented.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    128 views8 pages

    History Taking Form in Gynecology Obstetrics - Compress

    Uploaded by

    keight
    The patient presented with complaints of pain and bleeding. Their medical history included one prior pregnancy and no significant past medical or surgical history. A physical exam and review of systems found bleeding, abdominal pain, and fatigue. The chief complaint, history of present illness, past medical and obstetric history, review of systems, and physical exam were documented.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    At a glance
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    The document outlines the structure and components of a case report form used to collect a patient's medical history and review symptoms.

    Details about the current pregnancy, chief complaint, past obstetric and gynecological history, social history, allergies and past blood transfusions are collected in the patient's history.

    Any previous diseases, treatments and medications are documented in the past medical history.

    Case Report

    Date: / / 201

    PATIENT ID
    •Name: •Age:
    •Residency:
    •Marital Status:  Single  Married  Divorced 
    Widowed
    •Occupation:
    •DOA: / / 201 •Source of info:

    HISTORY OF CURRENT PREGNANCY:


    •G P A
    •LMP: •Blood Group: •Last
    Hb:
    •EDD:
    •Gestational age:
     Singleton pregnancy  Twin pregnancy:
    •Ultrasound?
    Why?

    Result?

    •Did you become pregnant while using birth control?


    •Are you currently experiencing any of the following?
    Nausea Vomiting Headache Fatigue
    Swelling
    CHIEF COMPLAINT

    Pain?
    HISTORY OF THE Vomiting?
    PRESENT ILLNESS Bleeding?
    -amount :
    -amount:
    -color:
    -color:
    S: -odor:
    -odor:
    O: hematemesis:
    w/ pain
    C: mucous:
    gush of fluid
    preceded by
    R:
    nausea?
    A:
    w/ pain?
    T: projectile non-
    HPI SUMMARY:

    PAST OBSTETRICAL HISTORY:


    •G P A .

    Place
    of NSI
    Duratio Type of
    Gende Weig deliver /
    # Year n of deliver complications
    r ht y/ IVF
    preg. y
    abortio *
    n
    1st
    2nd
    3rd
    4th
    5th
    6th
    7th
    8th

    PAST GYNECOLOGICAL HISTORY:


    •1st menarche: years old.
    •LMP: / / .
    •Regularity:
    •Period starts every day.
    •Duration of bleeding: days.
     Bleeding or spotting b/w periods.
    Contraceptives? pills
    IUD
    Pap smear? Why? When?
    Result?
    Pain w/ periods?
    before menses during menses
    both

    PAST MEDICAL HISTORY


    Disease When Drug(s)

    PAST SURGICAL HISTORY


    Surgery When Where Complication(s)

    DRUG HISTORY
    Drug Dose Frequency For (disease)

    FAMILY HISTORY
    Relationship Disease(s) Age diagnosed

    SOCIAL HISTORY
    Smoking:  Yes:  No
    Alcohol:  Yes:  No
    House Ventilation:  Well ventilated  Poorly
    ventilated
    Pets:  Yes:  No
    Pollution/Factories:  Yes:  No
    Travel:  Yes:  No
    ALLERGIES
    Drug/Food/Others Effect(s)

    BLOOD TRANSFUSION:

    SUMMARY:

    REVIEW OF SYSTEMS
    GENERAL
     Fever  Undocumented
     Documented
     Chills  Sweating
     Fatigue

    CARDIOVASCULAR SYSTEM
     Chest Pain: Site:
    Onset:  Sudden  Gradual

    Character:  Heaviness Stabbing  Burning


     Other:
    Radiation/Referral:
    Time:  Continuous Severity:

     Intermittent Frequency:

    Duration:
    Severity:
    Exacerbating Factors:

    Relieving Factors:

     Dyspnea: Onset:  Sudden  Gradual


    Time:  Continuous Severity:

     Intermittent Frequency:

    Duration:
    Severity:
    Exacerbating Factors:

    Relieving Factors:

     Orthopnea  PND 
    Dizziness/Syncope
     Palpitation  Edema
     Claudication Distance:

    RESPIRATORY SYSTEM
     Cough: Painful  Yes  No
    Dry/Wet:  Dry  Wet
    Sound:
    Time:
     Sputum: Amount:
    Color:
    Taste/Odor:
     Hemoptysis:Amount:
    Appearance:  Blood-streaked  Clots
    Frequency/Duration:
     Wheezing

    GASTROINTESTINAL SYSTEM
     Mouth ulcers
     Dysphagia:  Solids  Liquid  Both
     Intermittent  Continuous
     Complete obstruction with regurgitation  No
    regurgitation
    Level food get stuck in:
     Odynophagia
     Nausea
     Vomiting:  Preceded by nausea  Without warning
     With abdominal pain  Without pain
     Pain relieved after vomiting  Not relieved
     Related to meals
     Related to times:
    Amount:
    Color:
    Odor:
     Projectile  Non-Projectile

     Hematemesis: Amount:
    Appearance:  Coffee-ground  Fresh
     Preceded by retching (make the sound and movement of vomiting).
     Blood only appears after the first vomit
     Medications (NSAIDs/corticosteroids):

     Abdominal Pain: Site:


    Onset:  Sudden  Gradual
    Character:  Colicky  Constant  Twisting
     Tearing
    Radiation/Referral:
    Time:  Continuous Severity:

     Intermittent Frequency:

    Duration:
    Severity:
    Exacerbating Factors:

    Relieving Factors:

     Heartburn Relieved by:


     Weight loss (significant if >10% of weight in 6 months)
     Loss of appetite
     Altered bowel habit: Frequency  Increased
     Decreased
    Consistence  Watery  Soft 
    Hard
    Color:
    Odor:
    Blood:  Melena (tarry-stool) 
    Fresh
     Mucus  Pus  Tenesmus
     Urgency  Incontinence

    URINARY SYSTEM
    Color:
    Odor:
    Volume:  Normal  Increased  Decreased
    Frequency:  Normal  Increased  Decreased
    Stream:  Normal  Thick  Thin
     Dysuria
     Urgency
     Incontinence
     Nocturia
     Hematuria

    NERVOUS SYSTEM
     Headache: Site:
    Onset:  Sudden  Gradual
    Character:

    Radiation/Referral:
    Time:  Continuous Severity:

     Intermittent Frequency:

    Duration:
    Severity:
    Exacerbating Factors:

    Relieving Factors:

     Motor problems:
     Sensory problems:
     Change in personality/judgment:

     Convulsions
     Visual changes
     Auditory changes
     Tinnitus
     Dizziness

    MUSCULOSKELETAL SYSTEM
     Muscle pain
     Joint pain
     Exacerbated by movement (mechanical)
     Relieved by movement (inflammatory)
     Morning stiffness (inflammatory)
     Limitation in movement
     Joint swelling
     Deformities
    SKIN
     Rash
     Pain
     Redness
     Swelling
     Itching
     Pigment changes
     Discharge/Bleeding
     Hair changes
     Nail changes

    ENDOCRINE:
    •Alimentary changes:
    weight loss weight gain loss of appetite
    polydipsia
    •Integumental changes:
    pigmentation dryness
    sweating
    •Nervous changes:
    nervousness irritability headache
    seizures Fatigue Visual
    loss

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