1. BIODATA
Name
Age
Sex
Residence
Parity
LNMP
EDD
GBD
LD
IP No
DOA
(Post-op?)
2. P/C What problem(s) brought the patient to the hospital/ was it a referral? [symptoms] Duration (old→new)
3. HPI for each symptom
S-O-C-R-A-T-E-SPost cs/svd
B-U-B-B-L-E-H-Ea.Progress/course of disease
• Group related factors together
• Include direct unrelated questions to
rule out other conditions
b.Relevant past medical history
(HIV +ve, chronic illness, medications,
PAP smear or vaccine)
d.Intervention by who and where
- investigations,
- treatment plan, follow-up/
prognosis
e. Complications(GA,Rx,follow up)
f. Outcomes
ANC clinic
• planned/unplanned pregnancy
• where?
No. of contacts?
First and latest?
ANC profile
Bg&Hb,
VDRL,
HIV,
Hep B,
UECs
Rx and follow-ups
Rh: Was ICT done? Anti-D given? When?
Malaria ppx,
BP trends,
Deworming,
TT,
Antenatal supplements– Fe; folate; Ca
Others – OGTT for high-risk pts
Ob ultrasounds,
Past obs Hx
Year of delivery (termination & evacuation done?)
gestation date
Sex, BW, immediate cry;
Labour duration, Mode of delivery
neonatal complications; current status?
ANC – no. of visits;
complications (eg GDM, DVT, HIV diagnosis)
Complications after/before delivery? [baby milestones inquiry if labour is too long]
5. Gyn Hx
Menarche
cycle length
duration of flow
regularity;
colour
no pads/day
Clots
Flow
Dysmenorrhea
Sexual history
debut;
Life partners;
Dyspareunia(before, during, after)
STIs;
Tx
sexual abuse
Contraceptives
year used;
duration;
discontinuation reason;
AEs?
Pap smear;
VIA/VILI
HPV immunisation
Past gyn surg
yr;
place;
indication;
complications;
results of histology
Past gyn illness
Tx;
follow up
6. P medical & surgical Hx
Previous hospital admissions/surgeries?
Drugs/ allergies
Hx of blood transfusion
Chronic illness
age at diagnosis;
Tx;
follow up
7. FSHx
Occupation
Marital status
Fam members: Alive
Passed on
Chronic dx in the family?
Anyone in the family with sudden deaths
When
How
L
Alcohol, smoking, drug abuse
NHIF
Lindamama
8. RoS
Underline
Fatigue?
Headaches
Changes in weight?
Changes in appetite?
Trouble sleeping?
CVS
Chest pain
Palpitations
Dyspnea
Peripheral edema
Paroxysmal nocturnal dyspnea
Orthopnea
Syncope
Cyanosis?
Resp
Cough
Sputum colour, amount, and occurrence
Asthma or wheezing?
Dyspnea (shortness of breath)?
Painful breathing?
GIT
Dysphagia
Nausea or vomiting?
Change in appetite?
Abdominal pain
Abdominal distention/bloating
Jaundice (yellow eyes or skin)?
Diarrhoea?
Constipation?
Clay-coloured stools?
Bloody/pale/white/black stools?
GUT
Frequent urination?
burning or painful urination
Polyuria/oliguria?
Nocturia
Hematuria
Incontinence?
Musculoskeletal
Muscle or joint pain?
Joint stiffness?
Muscle weakness?
Cramps?
Trauma?
Back pain?
Neurological
Change in memory?
Recurring or frequent headaches?
Dizziness?
Fainting?
Convulsions or seizures?
paresthesia/numbness, tingling)?
Vertigo
Tremor?
Ears eyes n nose
Tinnitus
Loss of hearing
Blurry vision
Blocked nose