History obstetrics and gynecology PowerPoint

Presenting

1. Ob/Gyn. History taking and
examination
•Professor Mohamed Ahmed A. E. Ounsa
•Consultant of obstetrics/gynaecology and
IVF
•The National Ribat University
•MD, PhD, MHPE, DIVF, DRMRB,
DRMBS, ADUS, DUS,PDUS, DAG,
DMAS,FMAS, MBBS

2. Obstetrics;
Science that deals with pregnancy
and child birth.
Gynecology;
Science that deals with the
diseases of the female genital tract.

3. History taking;
(Personal data):
-Name: (4).eg. Aish Hassan Ahmed A.Alla
-Age:
-Occupation:
-Residence:

4. -Marital status:
single, married, divorced, separated,
widow.
> If married; duration, husband name, age,
education, occupation, consanguity.
-Education level:
-Tribe:

5. -Date of admission:
-Cause of admission C/O:
-Amenorrhoea / 3/12.
-Nausea / 6/52
-Constipation / 4/52

6. Gyn.H: -Menarche.
-kata : eg. 5/28
> Regularity.
> Amount; normal, scanty, heavy.
> Dysmenorrhoea; 1ry, 2ndry.

7. > Vaginal discharge;
(physiological, pathological).
If pathological;
trichomoniasis,moniliasis,bacterial.
> Contraceptives; cocs, inj.post pill
amenorroeawrong dates.
> Lactation; anovulationwrong dates.
> LMP
> EDD
> GA (weeks)

8. Obs.H: No.pregnancies, No.parities,No. abortions.
eg. G2 p1 plus zero.
-Parity; GA, mode of delivery (if operative 
indication, place, who attended, out come, sex,
complications (maternal,foetal), blood
transfusion.
-Abortion; type, GA, obvious reasons,
evacuation, complications, blood transfusion.

9. -Primigravida = pregnant for the first time.
-Multigravida = pregnant for 2
nd
–4
th
time.
-Grandmultigravida = ≥ 5
th
pregnancies.
-Primipra = Having one delivery.
-Multipra = Having 2 –4 deliveries.
-Grandmultipra = ≥ 5 deliveries.
-Nullipra = Having no baby.

10. -Past history: DM, hypertension etc.
-Surgical History:
-Family history: DM, hypertension, multiple
pregnancy, congenital malformation.
-Drug history: hypersensitivity, chronic
medication.
-Social history: poor, moderate, high.

11. -History of present illness: (c/o detailed)
-History of current pregnancy:
>1
st
trimester; nausea, vomiting, hyper
emesis gravid arum, vaginal bleeding.
> 2
nd
trimester; A.N.C, quickening, vaginal
bleeding, UTI, anaemia.
> 3
rd
trimester; vaginal bleeding, excessive
wt.gain, swelling.
-Systematic review;
-Summary;

12. Physical examination
-General condition; ill, well, etc.
-Stature (PG)
-Gait
-Eyes, paleness, jaundice, cyanosis.
-Pulse (rate, rhythm, volume, synchronicity,
character, radio femoral delay)
-BP
-Mouth (paleness, cyanosis, hygiene, teeth
(caries, denture)

13. •Neck; thyroid, L.nodes
•Chest; -Breast; inspection (( development,
contour, colour, nipple( inverte -everted-
flat), scars, cracks, fissures, areola (1ry,
2nry), Montogomry tubercle, palpation(6
areas –upper and lower median, upper
and lower lateral, centre, axillary's tail),
breast activity))
-Respiratory system
-CVS

14. •Abdomen;
•> Inspection; distention (symmetrical,
• asymmetrical), pendulous, umbilicus
• (inverted, everted, flat), linea nigra, striae
• gravid arum, scars, cautery scars, foetal
• movement.
•> Superficial palpation; temperature,
• superficial masses, tenderness.
•> Deep palpation; spleen, liver, kidneys

15. •Obstetric examination;
> fundal level GA in wks.
> fundal grip the part in the fundus.
> lateral grips (Rt,LT)lie and position.
> pelvic grips; 1
st
presentation
2
nd
engagement (PG).
> foetal heart sound.
> amniotic fluid estimation.
> foetal wt estimation.

16. •Lower limbs; oedema, varicose veins
•Vaginal examination, speculum
•examination, bimanual examination.
•Clinical pelvic assessment.

17. •Definitions:
•Lie; Relationship between the longitudinal
axis of the foetus to the longitudinal axis of
the mother
•Position; Relationship between a certain part
of the foetus to the 4 quadrant of the pelvis.
•Presentation; is that part of the foetus that
occupy the lower segment.
•Attitude, is the relationship between the
various foetal parts to each other