Sample OB-GYN History

Date and time gathered:
Source/informant:
% reliability:
A. General data
R.L., 26 years old, female, married, G3P2, 40 weeks and 3 days AOG,
Filipino, R. Catholic, salesgirl, born on Mar. 5, 1995 in Liloan, Cebu , residing in
Mabolo, Cebu City, was admitted at CDUH on March 23, 2021, for the third time.
B. Menstrual History
She had her menarche at 12 years old which lasted for 3 days with
moderate flow consuming 2-3 pads a day. Succeeding menses lasted for 3-5 days,
with regular 28-day cycle, moderate flow using 4 soaked pads per day. She does
not experience dysmenorrhea. She has not taken oral contraceptives or hormones
and has not had intermenstrual bleeding
Her last menstrual period (LMP) was on June 13, 2020 and past/previous
menstrual period (PMP) was on May 15,2020
C. Obstetric History
Her OB Score is G3P1(F1P0A1L1}
Previous Pregnancy
G1 – Jan. 20, 2016, 38 weeks AOG, 20 hours labor, thru normal
spontaneous, vaginal delivery (NSVD), 7 lbs,, female, no
complications
G2 - Abortion, Oct. 11, 2018, CDUH, 18 wks AOG, spontaneous, D&C by
Dr. Flores (Obstetrician ), stayed 3 days in hospital, no complications
Present pregnancy
LMP - June 13, 2020
EDC - March 20, 2021
AOG - 40 weeks and 3 days
D. Prenatal History
Her first prenatal check up was on Nov. 5, 2020at CDUH by an
OB resident. She had regular check ups and last visit was on Mar. 1
2021. CBC, urinalysis, fasting blood sugar and pap smear were all
normal. Ultrasound done on Oct. 25, 2020 (AOG 14 weeks 6 days)
was unremarkable. Quickening was felt on Oct. 8,2020. Her prenatal vitamins
(Trihemic) were supposed to be taken once a day but sometimes she forgot to take. She
was given Tetanus toxoid vaccine for 2 doses at 24 and 28 weeks AOG. Her weight gain
is 10 kilos and usual BP is 110/65 mm Hg. She did not get sick while pregnant.
E. Contraceptive History
They used condom for birth control for one year without complaints
but stopped to have another baby.
F. Sexual History
Her coitarche was at 21 years old and the husband is her only sexual partner.
They are compatible with good sexual interest, function and satisfaction. They
have sex 2x a week.
G. Past Medical History

She had measles at 2 years old, mumps at 5 years old and chicken pox
at 10 years old. She had no childhood immunizations. She received
Hepatitis B vaccine in 2017 for one dose only. She was admitted at CDUH on
Jan. 20, 2016 for her first delivery and on Oct. 11, 2018 for D&C. There were no
complicatins for both admissions.
She has no history of any serious injuries, no serious illnesses and no
psychiatric problems.
H. Personal or Social History

She has been married for 4 years to a healthy security guard and they are
compatible. She does not smoke nor drink alcoholic beverages. She's a high
school graduate and works as a salesgirl. She's not a drug user and sleeps
8 hours a day without aid of sedatives and has no allergies.
She is a high achool graduate and has been a salesgirl for 5years.
Her workplace is safe without occupatinal hazards. Their combined income
their daily needs and lifestyle. They travelled to Davao City last Dec. 23, 2019.
She has a 5-year old daughter who is healthy.
I. Family History
Father died of lung cancer last Aug. 8, 2015 at 55 years old.
Mother is 51 years old, dressmaker, hypertensive and takes Catapres 25mg
once a day. Her only sibling is a 23-year old male, student and healthy. Her
family has no history of twinning, difficult deliveries, toxemias of pregnancy
and congenital anomalies.
J. Chief complaint : labor pains
H. History of Present Illness

The present condition started 20 hours prior to admission as sudden
onset of irregular, crampy, non-radiating hypogastric pain lasting for 15
sec. with an interval of 1-2 hours. Painscale was 3. No medications were
taken but rest slightly and temporarily relieved the pain.
Two hours PTA, pain was still irregular lasting for 30 sec, with
interval of 5 min. Pain radiated to the lower back and slight bloody and
mucoid vaginal discharges were noted. Baby's movement and heart tones
were normal. No medications were taken. Rest no longer afforded relief.
Painscale was 6.
Her urination and bowel movement were not affected and sleep
was interrupted due to pain and had no appetite.
One hour PTA, pain became severe with painscale of 9. Contractions
became regular lasting for 40 sec. with interval of 3 min. Pain still radiated to
the lower back. Copious watery and slightly bloody vaginal discharge was
noted. Due to the severe pain and copious vaginal discharges she sought
admission.
COMPUTATIONS
For EDC:
LMP - June 13, 2020
6 13 2020
- 3 +7 + 1
3 20 2021
EDC - March 20, 2021
For present AOG:
LMP - June 13, 2020
June - 17
July - 31
Aug. - 31
Sept. - 30
Oct. - 31
Nov. - 30
Dec. - 31
Jan. - 31
Feb. - 28
Mar. - 23
____
283
If computing manually : - AOG = 283 / 7 = 40 weeks and 3 days
If using calculator: 283/7 = 40.42

Multiply .42 x 7 = 2.94
AOG = 40 weeks and 3 days
AOG at first prenatal check up
Date : Nov. 5, 2020

June - 17
July - 31
Aug. - 31
Sept. - 30
Oct. - 31
Nov. - 5
_____
145
145/7 = 20.71
.71 x 7 = 4.97 AOG = 20 weeks and 5 days
AOG at Ultrasound
Date: Oct. 25, 2019

June - 17
July - 31
Aug. - 31
Sept. - 30
Oct. - 25
134
134/7 = 19.14
.14 x 7 = .98
Quickening - Oct. 8, 2020

June - 17
July - 31
Aug - 31
Sept. - 30
Oct. - 8
____
117
117/7 = 16.71
.71 x 7 = 4.97
GP(FPAL)
G - Gravida - Total number of times pregnant including present pregnancy and abnormal
pregnancies. Multiple pregnancies are counted as 1 pregnancy.
P - Parity - Viable births of more than 20 weeks gestation. Multiple pregnancies
reaching viability are counted as 1.
F/T - Full term ( 37 and above)
P - Preterm ( 20 to 36 weeks and 6 days)
A - Abortion ( below 20 weeks)
L - Living

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Sample OB-GYN History

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Date and time gathered:

G. Past Medical History

H. Personal or Social History

J. Chief complaint : labor pains

H. History of Present Illness

If using calculator: 283/7 = 40.42

AOG at first prenatal check up

Date : Nov. 5, 2020

Date: Oct. 25, 2019

Quickening - Oct. 8, 2020

AOG = 16 weeks and 5 days

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