OBGYN OSCE - COMPLETE OB History

1. Greets the patient and introduce self to patient

2. Explains the purpose of the interview
3. Uses language/vocabulary that is appropriate and understandable
4. Ask about the General Data of the patient
 Name, Age, Date of Birth, Marital Status, Religion, Residence
 OPD/For admission? Note the date
5. Chief Complaint of the Patient
6. Inquire about the General well-being of the patient (Ask more details about the Chief
Complaint) History of Present Pregnancy (OB)
 Ask about patient concerns regarding current pregnancy
Ask about the main patient concern in ORGANIZED AND SEQUENTIAL MANNER
o First Trimester
o Second Trimester
o Third Trimester – till admission
 Ask about other symptoms, if any
i. Appetite, N/V
ii. Fetal Movement (Quickening: Primi 18-20wks, Multi 16-18 wks aog)
iii. Abdominal Cramps (Braxton Hicks – 28 wks aog)
iv. Back pain/Labor pains
1. Onset of Uterine Contractions
2. Time of Onset
3. Point of reference (how many hours prior to consult/admission)
v. Bleeding (1st trim: SABs, EP, 2nd or 3rd trim: AP, PV, UTI) Bloody show if
near term
vi. Vaginal Discharge (color, odor, amount, consistency)
History of Present Illness (GYN)
 In relation to chief complaint (Pelvic Mass/Bleeding etc)
 Duration (onset)
 Associated symptoms ( pain, urinary, bowel changes, weight loss)
7. Prenatal check ups (Past and Present)
 Number / Frequency
 Institution ( health center/ private MD)
 Date of last check up
 Diagnostics done: Laboratory and ultrasound
 Medications taken: past and present
8. Menstrual History: Ask the following
 Age of menarche
 characterises subsequent menses according to:
i. Interval
ii. Duration
iii. Amount (# of pads used per day)
 iv. Ask about my associated symptoms e.g dysmenorrhea, headache,
diarrhea
9. Last menstrual period
10. Past menstrual period
 Compute for AOG (LMP to present then / 7)
 Computes for expected date of confinement (EDC) based on the LMP
11. Proceeds to obtain for OB history ( facilitator gives scenario)
 Able to get the correct OB score GP (TPAL)
 For each:
i. Year delivered
ii. AOG (Full term/Preterm/Abortion) and Gender
iii. Manner of Delivery
iv. Birthweight
v. Place of Delivery
vi. Complications, if any
12. Past Medical History
 DM, HTN, Asthma, Thyroid Problems, Cancer, Seizure, STDs
 Previous hospitalizations, surgeries (appendectomy, cholecystectomy) and blood
transfusions
 History of exposure to DES
 Allergies to food/drug
13. Family History on either both sides
 Hypertension, DM, Asthma, Pulmo dse Cardiac dse, Cancer, Breast tumor,
Cervical tumors
14. Personal and Social History
 Occupation (Housewife, how many years)
 If married, how many yrs married, ask for work of husband and how many years
working
 Smoking (Packs/day, how many years, pack-years) If stopped, since when
 Alcohol (what kind?) Coffee?
 Drug Use
15. Sexual and Gyne History
 First coitus at age
 How many sexual partners past and current partners
 Use of barriers or OCPs, year
 Any associated dyspareunia, leucorrhea, postcoital bleeding
 Any papsmear done? Result
16. Review of Systems
 General: fever, seizure, weight loss, chills
 Skin: lumps, sores, itching, dryness, discoloration
 HEENT: dizziness, LOC, eye pain, redness, tearing, hearing loss, vertigo, ear
discharge, bleeding gums, sore throat, hoarseness
 Cardiac: palpitations, chest pain
  Lungs and Thorax: cough, DOB, hemoptysis
 GIT: polyphagia, constipation, diarrhea, n/v
 Urinary: polyuria, oliguria, dysuria, hematuria
 Endocrine: polydipsia, heat/cold intolerance
 Musculoskeletal: joint pains
 Psychiatric: sleep disturbances, suicide attempts, nervousness
 Neurologic: vertigo, numbness, tingling sensation
17. Entertain and answer Patient’s questions adequately
18. Thanks the patient after the interview