Taking a good history is very important in making a proper and most appropriate diagnosis. And it is applicable to all specialties of the medical field.

1. Dr.Suresh Babu Chaduvula
Professor
College of Medicine
King Khalid University
Abha, KSA

2. Respect, confidentiality and privacy are
important
Information should be logical and also in
chronological sequence
History should guide a clinician to make a
provisional diagnosis and perform proper and
relevant investigations

3. To build a rapport with the patient
To come to a provisional diagnosis
To perform relevant investigations
To give correct treatment
To provide proper counseling

4. Seek permission from the patient, Greet the
patient
Dress code with Apron and identity badge
Make sure a sister or a female attendant be
with you.
Be gentle and sensitive

5. Biodata [ personal and social hstory]
Name :
Age:
Nationality:
Occupation:
Marital state:
Relation:
Wife/ Daughter of:
Address:
Obstetric Formula: Gravida, Parity, Abortions,
Ectopic pregnancy
LMP
EDD

6. Gravidity – No. of pregnancies including this
pregnancy
Parity: No. of births beyond 24 weeks
Abortion is termination before 24 weeks
EDD can be calculated by ‘Naegele’s rule’ by
adding 7 days and 9 months to 1st day of Last
menstrual period.
Hijri calendar - add 9 months and 15 days
Formula will be G3P1+1+1 at 8th month for a
woman who is pregnant third time, parity one
with one abortion with one live child at 8th
month of gestation.

7. Naegele’s rule needs to be adjusted or
recalculated in following conditions for
accuracy:
1. Irregular periods
2. Women on contraceptive pills
3. Prolonged periods
Early scan is important in estimating EDD

8. 2. Complaints and Duration: [ chronological order ]
Pain, Vomiting, Bleeding, Discharge, Fever etc.
3. History of present illness:
Elaborate or expand each complaint in chronological order.
Explain the events happened in the hospital stay and what
treatment she received.
1st Trimester
2nd Trimester
3rd Trimester
History of labor

9. Trimester wise History:
1st Trimester – History of Pain lower abdomen,
Bleeding per vagina, fever with chills and rigors,
skin rash, intake of any drugs, radiation
exposure, UTI symptoms
Any investigations like ultrasound, urine
pregnancy tests and any blood tests.
History of any operations or any other trauma or
interventions done.
Drug and vaccination history
Whether she is booked with any doctor, if so how
many visits she has had

10. 2nd Trimester:
History of Pain lower abdomen, Bleeding per vagina, fetal movements, symptoms of
anemia, Hypertension, APH and hyperemesis
Time of Quickening: [ first perception of fetal movements ] – Primi – 18 – 20 weeks,
Multi – 16-18 wk
Weight gain – [ 5 kg ]
H/O of headache, blurring of vision, edema of feet, change in the color and
quantity of urine.
Any investigations like ultrasound, urine pregnancy tests and any blood tests.
Immunization history.
History of any operations or any other trauma or interventions done.
Whether she is booked with any doctor, if so how many visits she has had
History of any drugs taken

11. 3rd Trimester –
History of Pain lower abdomen, Bleeding per vagina.
Weight gain – [ 5 kg ]
H/O of headache, blurring of vision, edema of feet, change in
the color and quantity of urine.
Any investigations like ultrasound, urine pregnancy tests and any
blood tests.
History of any operations or any other trauma or interventions
done.
Whether she is booked with any doctor, if so how many visits she
has had
History of drugs intake
If it is Postnatal case:
Labor and delivery details and postnatal period.

12. Gravida, parity and Abortions
Elaborate each pregnancy like date and time
of delivery
Is it full term or preterm delivery
Hospital or home delivery
Normal or cesarean delivery
Male or female baby
Weight of the baby
Any complications in the delivery
Any problems for the newborn

13. Duration of cycle
No. of days of flow
Regularity
LMP
EDD

14. Usage of oral pills, IUCDs, Barriers,
Duration and any side effects

15. Any history of medical illnesses like,
Tuberculosis, Diabetes, hypertension,
Epilepsy, SLE etc.
Is she on treatment
Is she following up with any physician
What type of surgery she had undergone

16. Any history of medical illnesses like,
Tuberculosis, Diabetes, hypertension, SLE,
Congenital anomalies, Heart diseases,
Multiple pregnancy
Chromosomal diseases and metabolic
diseases
H/O Consanguinity.

17. To drugs
To food
Any others

18. Occupation
Income or Living Status
Level of education
Total family members
AND
Smoking
Alcohol intake
Drug abuse
Sleep, Bowel habits, Diet

19. Look for pallor, cyanosis, jaundice, hydration
status, oral hygiene.
Thyroid and any neck swellings
Breast examination:
Koilonychia, Clubbing
Edema feet, varicose veins in legs
Vital signs:
BP – in semi-recumbent position at 45 degrees
PR,RR,Temperature:
Weight in Kg:
Height in Cm:
Calculate BMI = Wt[kg]/Ht[mt square]

20. CNS
CVS
Respiratory System
GIT
Genitalia
Urinary system
Locomotory system

21. INSPECTION:
Size of abdominal distension
Symmetrical or Asymmetrical
Umbilicus – Inverted, flat or Everted
Fetal movements
Scars
Engorged veins
Hernia sites: Umbilical, Para-umbilical,
Inguinal

22. LINEA NIGRA: a dark pigmented line from
xiphi-sternum to symphysis pubis
STRIAE GRAVIDARUM: recent stretch marks
are purplish in color
STRIAE ALBICANS: old stretch marks look
silvery white

23. PALPATION:
Symphysio-fundal height: measured in
centimeters
Measured from 20 weeks onwards
Estimation of no. of fetuses
If it is a single fetus –perform Leopold
maneuvers:
1. Fundal height and Grip
2. Lateral or Umbilical grip
3. Superficial or Pawlic’s grip
4. Deep pelvic grip

33. Mrs.-------------- is a 21 year old Saudi house
wife married for 2 years Primi or G4, P3, A0
and living 3 at 33 weeks admitted with high
blood pressure for admission and further
management.

34. Bio-data is same
Complaints and duration –
Abnormal uterine bleeding
Infertility
Vaginal discharge
Pelvic pain
History of present illness:

35. Age of menarche
Duration of cycle
Amount of flow
Pain with periods – Dysmenorrhea
Premenstrual symptoms
Inter menstrual spotting or bleeding
Date of LMP

36. Obstetric History:
Past & Surgical History:
Family History:
Treatment History:
Allergy History:
Sexual history:
Husband
Prevention of pregnancy
Protection against STDs
Practices
Social and Personal History:

37. Past Gynecological history
Any previous PID, Endometriosis, fibroids, etc
Any operations
HRT

38. General Examination
Systemic Examination
Abdominal examination
Local or Genitalia examination
Per speculum examination
Per vaginal or Bimanual pelvic examination
Vagino-rectal examination
Provisional diagnosis
Differential diagnosis

39. Mrs.----------- Saudi, 17 year old, complaining
of vaginal discharge for evaluation and
management

40. Thank You All