Obstetric and Gynecological Case History: Template, Example, and Generator

Template for the Obstetric and Gynecological Case History

Sections in the order expected by most academic departments. The generator uses this exact structure; if your department requires a specific format, upload it as a template.

1. 1
   General patient data

   Age (not date of birth), gender, occupation/profession (omit organization name), date and time of admission, department, referral source/delivery method, referring facility diagnosis, admission diagnosis. Do not include full name, address, or document numbers: use "Patient N."

2. 2
   Complaints

   Chief complaints with details (localization, character, intensity, radiation, duration, triggers, and relieving factors) along with general symptoms; complaints upon admission and at the time of examination.

3. 3
   History of the present illness (Anamnesis morbi)

   Onset and progression, initial symptoms, clinical course, previous medical consultations, prior diagnostic tests and treatments before admission along with their efficacy, as well as the reason and circumstances of hospitalization.

4. 4
   Past Medical History (Anamnesis vitae)
5. Brief biographical data, living conditions, and dietary habits

   Birthplace and upbringing, education, housing and living conditions, dietary habits, physical activity.

6. Occupational history

   Profession, length of service, working conditions, occupational hazards (without naming the organization).

7. Past medical history, surgeries, injuries

   Childhood infections, chronic diseases, surgeries, trauma, tuberculosis, viral hepatitis, STIs, blood transfusions (with reactions).

8. Bad habits

   Smoking (duration, pack-years), alcohol (frequency, quantity), illicit drug use.

9. Medication history

   Regular medications taken by the patient (name, dose, frequency).

10. Allergic history

    Drug, food, and household allergen intolerance; type of reaction.

11. Epidemiological history

    Contact with infectious patients, travel outside the region/country over the past 6 months, parenteral interventions, bites, dietary history, contact with animals.

12. Family history

    First-degree relatives' medical history (CVD, diabetes mellitus, oncology, tuberculosis, psychiatric conditions).

13. Insurance history

    Certificate of incapacity for work (duration), disability group.

14. 5
    Special Obstetric and Gynecological Anamnesis
15. Menstrual function

    Menarche, establishment of the cycle, cycle and menses duration, blood loss volume, dysmenorrhea, date of last menstrual period.

16. Sexual function and contraception

    Age of coitarche, marital status, contraception methods.

17. Reproductive function

    Number of pregnancies, births, induced abortions, miscarriages: by years, course and complications, birth weight of children.

18. Past Gynecological Diseases and Surgeries
19. 6
    Course of Current Pregnancy
20. 7
    Objective examination (Status praesens objectivus)
21. General physical examination

    General condition, level of consciousness, body position, physique, body type, height, body weight, BMI, body temperature; skin and visible mucous membranes, subcutaneous adipose tissue, edema, lymph nodes, muscles, bones, joints.

22. Respiratory system

    Chest inspection, respiratory rate, palpation (resistance, vocal fremitus), comparative and topographical percussion, auscultation (breath sounds, rales, crepitation, pleural friction rub), bronchophony, SpO2.

23. Cardiovascular system

    Inspection of the heart and neck vessels, apex beat, boundaries of relative cardiac dullness, auscultation (heart sounds, murmurs), pulse (rate, rhythm, volume, tension), blood pressure on both arms, peripheral arterial pulsation.

24. Digestive system

    Oral cavity, tongue, abdomen (inspection, superficial and deep palpation according to Obraztsov-Strazhesko, percussion, auscultation), liver dimensions according to Kurlov, gallbladder (symptoms), spleen, stool.

25. Urinary system

    Lumbar region inspection, kidney palpation, tapping sign (Pasternatsky's sign), urination, diuresis.

26. Endocrine system

    Thyroid gland (palpation, eye signs), subcutaneous fat distribution, secondary sexual characteristics.

27. Nervous system and sense organs

    Consciousness, orientation, sleep, memory, meningeal signs, focal symptoms, reflexes, vision, hearing.

28. 8
    Special Status (Status obstetricus / genitalis)
29. External obstetric examination

    For pregnant patients: abdominal circumference, fundal height, pelvic dimensions, Leopold's maneuvers (lie, position, presentation, part presenting), fetal heart rate, estimated fetal weight.

30. Speculum examination

    Vaginal and cervical mucosa, discharge.

31. Vaginal (bimanual) examination

    Cervix (Bishop score maturity in pregnant women), uterine body, adnexa, fornices, parametria.

32. 9
    Preliminary diagnosis and its rationale

    Identify syndromes based on complaints, history, and objective data, justify each; formulate a preliminary diagnosis.

33. 10
    Examination plan

    Laboratory and instrumental studies and consultations with the purpose of each: according to clinical guidelines of the Russian Ministry of Health (mandatory and as indicated).

34. 11
    Results of laboratory and instrumental studies

    All available results with dates (in a table where appropriate) and interpretation: what is normal, what is abnormal, and what it means. Unperformed/missing studies should be listed as "no data".

35. 12
    Differential diagnosis

    At least 2–3 diseases with a similar presentation: for each, common features and differences used to rule it out (based on this patient's data).

36. 13
    Clinical diagnosis and its rationale

    Formulation according to clinical guidelines and ICD-10 classification (code): primary disease, complications of primary disease, concomitant diseases; justification for each component. For pregnant patients: gestational age, fetal lie and presentation, obstetric complications, extragenital pathology.

37. 14
    Etiology and pathogenesis

    Etiology and pathogenesis of the disease in general and applied to this patient (risk factors, mechanisms of syndrome development).

38. 15
    Treatment and its rationale

    Regimen, diet, non-pharmacological treatment, pharmacotherapy: drug (INN), dose, route, frequency, duration, and justification with reference to clinical guidelines; At the end: prescriptions in Latin (Rp.: … D. S. …) for 2–3 main drugs. For pregnant patients: pregnancy/delivery management plan, mode of delivery; consider drug safety during pregnancy.

39. 16
    Observation notes

    prescriptions).

40. 17
    Stage (discharge) epicrisis

    Briefly: patient, age, date of admission, reason for admission, main examination results, clinical diagnosis, treatment performed and its effect, condition at the end of curation, recommendations.

41. 18
    Prognosis and recommendations

    Prognosis for life, for recovery, for working capacity (with justification); discharge recommendations and follow-up care according to clinical guidelines.

42. 19
    References

    formatted according to GOST R 7.0.100-2018.

Case History Scheme in Obstetrics and Gynecology: Additions to the General Scheme

Standard framework: complaints, anamnesis, objective status, diagnosis, plan, treatment. However, the central sections differ. For a pregnant or parturient woman, these are the special anamnesis and obstetric examination; for a gynecological patient, it is the gynecological status. These are precisely what the instructor reads most carefully.

Special Anamnesis

• Menstrual function: age at menarche, cycle and menses duration, regularity, dysmenorrhea, first day of the last menstrual period.
• Sexual function and contraception.
• Reproductive function: all pregnancies in chronological order with year, gestational age, and outcome (birth, medical abortion, spontaneous miscarriage, ectopic pregnancy) and complications.
• Gynecological diseases and surgeries.
• Course of current pregnancy by trimesters: gestational age at registration, screening results, weight gain, hospitalizations.

Gestational Age and Due Date

Gestational age is calculated from the first day of the last menstrual period and refined by first-trimester ultrasound (crown-rump length). The estimated date of delivery (EDD) based on menstruation is calculated using Naegele's rule: subtract 3 months from the first day of the last menstrual period and add 7 days. If the first-trimester ultrasound gestational age differs significantly from the menstrual age, rely on the ultrasound; indicate in the history which age was adopted and why.

External obstetric examination

This includes fundal height and abdominal circumference, pelvic dimensions (distantia spinarum, distantia cristarum, distantia trochanterica, conjugata externa), Michaelis rhombus, Soloviev's index, and four Leopold's maneuvers. The first maneuver determines the fetal part in the uterine fundus; the second determines the lie, position, and back location; the third determines the presenting part; the fourth determines its relation to the pelvic inlet. Fetal heart rate is auscultated with a stethoscope or assessed via cardiotocography (CTG); the normal baseline rate is 110–160 bpm. Estimated fetal weight is often calculated using Jordania's formula: fundal height × abdominal circumference.

Cervix and Gynecological Status

At term pregnancy, cervical maturity is assessed using the Bishop score: cervical position, length, consistency, patency of the cervical canal, and station of the presenting part. 8 points or more: mature cervix; 6–7 points: insufficiently mature; 5 or less: immature. For a gynecological patient, instead of the obstetric examination, describe the speculum and bimanual examinations: position, size, consistency, mobility, and tenderness of the uterus, condition of the adnexa, fornices, and parametria.

Obstetric Diagnosis

Standard order: gestational age in weeks, fetal lie and presentation (often with position and view), stage of labor (if in labor), then pregnancy complications, followed by extragenital diseases and burdened anamnesis. Many departments request parity as well, for example, "Pregnancy II, pending delivery I." ICD-10 codes are assigned under class O for complications (e.g., O24.4 for gestational diabetes mellitus), while uncomplicated pregnancies use category Z34.

Obstetric Case History Example: 38 Weeks Pregnant

Fragments of a model history. The patient is fictional, and the figures are educational.

Special Anamnesis (Fragment)

Patient K., 29 years old. Menarche at 13 years, cycle of 28 days, menses lasting 5 days, moderate, painless. First day of the last menstrual period: January 3, 2026. Second pregnancy: the first in 2023 ended in a spontaneous miscarriage at 7 weeks. Registered at 8 weeks. At 25 weeks, an oral glucose tolerance test with 75 g of glucose was performed: fasting 5.4 mmol/L, 1 hour 10.3 mmol/L, 2 hours 8.1 mmol/L. Gestational diabetes mellitus was diagnosed, diet therapy was prescribed, and glycemic targets were achieved. Complete blood count at 37 weeks showed hemoglobin of 104 g/L.

On the day of observation, September 26, 2026, the gestational age by menstruation is 38 weeks 0 days, matching the gestational age by 12-week ultrasound. Estimated date of delivery by Naegele's rule: October 10, 2026.

External Obstetric Examination (Fragment)

Pelvic dimensions: 26-29-31-21 cm, Soloviev's index 14 cm. Fundal height 36 cm, abdominal circumference 98 cm, estimated fetal weight by Jordania 36 × 98 ≈ 3500 g. Leopold's maneuvers: a large, soft, irregular part in the uterine fundus (pelvic pole); the back is palpated on the left and anteriorly; the presenting part is a dense, rounded part (head), mobile above the pelvic inlet. Fetal heart rate is clear, rhythmic, 140 bpm, heard on the left below the umbilicus. Cervix scores 6 points on the Bishop scale: insufficiently mature.

Clinical Diagnosis

Pregnancy II, 38 weeks. Longitudinal fetal lie, first position, anterior variety, cephalic presentation.

Pregnancy complications: Gestational diabetes mellitus, diet therapy (O24.4). Mild anemia of pregnancy (O99.0).

Burdened obstetric anamnesis (spontaneous miscarriage).

Justification and Plan (Brief)

Gestational age is confirmed by the concordance of the menstrual age and the first-trimester ultrasound. Fetal lie, position, variety, and presentation were determined by Leopold's maneuvers: the back on the left indicates the first position, anteriorly indicates the anterior variety. Gestational diabetes mellitus was diagnosed based on test criteria (fasting value of 5.1 mmol/L or higher, 1 hour 10.0 or higher, 2 hours 8.5 or higher; a single abnormal value is sufficient). Anemia: hemoglobin below 110 g/L in the third trimester.

Plan: glycemic profile via self-monitoring log, CTG, ultrasound with dopplerometry and estimated fetal weight assessment, repeat complete blood count and ferritin, determine the timing and mode of delivery. Verify the tactics against the clinical guidelines for "Gestational Diabetes Mellitus" and "Normal Pregnancy" under clinical guidelines.

Common Mistakes in Obstetric and Gynecological Case Histories

• Gestational age is stated without explaining how it was calculated, and the estimated date of delivery does not match it.
• Leopold's maneuvers are listed by name, but no conclusion is drawn regarding lie, position, variety, and presentation.
• The position is determined incorrectly: it should be determined by the fetal back (back to the left: first position, to the right: second).
• Fetal presentation is confused with placental presentation.
• The diagnostic order is violated: complications precede gestational age, and extragenital pathology is mixed with obstetric conditions.
• Complications are listed without criteria: no glucose, blood pressure, urine protein, or hemoglobin values are provided.
• The cervix is described as "maturing" without evaluation using the Bishop score.
• The gynecological patient lacks a gynecological status: speculum examination and bimanual palpation are replaced by a description of the abdomen.
• Real full name, date of birth, case record number, or patient address have been included. This violates medical confidentiality (Article 13 of Federal Law No. 323-FZ) and personal data regulations (Federal Law No. 152-FZ): write the biographical and administrative section anonymously.

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