Obstetrics History

Patients Profile MR#: ________________________

Name:_____________________________________Husbands/Fathers Name:_____________________________

Age:_____________________________________Husbands Age: _____________________________

Education:_____________________________________Husbands Education: _____________________________

Occupation:_____________________________________Husbands Occupation: _____________________________

Blood Group: _____________________________________Husbands Blood Group: _____________________________

Married for (Yrs): _____________________________________Consanguinity: Yes/No

L.M.P:_____________________________________

Parity:_____________________________________Phone:_____________________________________

EDD: _____________________________________Residence:_____________________________________

Presenting complaint: __________________________________________________________________________

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Past Obstetrics History

Year of Birth

Place of Birth

Duration

Complication

Mode of Delivery

Sex

Birth Weight

Breastfed

Current Health Status

History of Present Pregnancy

1st TrimesterPregnancy: planned/unplanned Confirmed by: _____________________________________ Booking: done/not done, where: ____________________________Spontaneous/Induced (by what) ______________________Investigations: _________________________________________________________________________________________________Fever, rash, spotting, bleeding, nausea, _____________________________________________________________________________Any treatment: _____________________________________________Folic acid: yes/no

2nd TrimesterAnomaly scan: ____________________________________________Quickening: _______________________________________

Any complications: _________________________________________Urinary tract infection: ______________________________

Bleeding: ________________________________________________Vaginal discharge: __________________________________

Medical disorder (Diabetes/ Hypertension): _______________________________________________________________________________________________________________________________________________________________________________________

Tetanus Prophylaxis: yes/no 1st Dose: _________________2nd Dose: __________________

Investigations: _________________________________________________________________________________________________Any treatment received: ____________________________________Vitamin, folic and calcium supplements: ________________

3nd TrimesterFetal movements approx. / day: _______________________________Abdominal pain/ contractions: ________________________

Bleeding: _________________________________________________Fever: ___________________________________________

Vaginal Discharge: Color _____________ Amount ____________itching (yes/no)Consistency _________________

Urinary complaints: _________________________________________Bowel complaints: _________________________________

Hypertension: ____________________________________________ Diabetes: ________________________________________

Investigations: _________________________________________________________________________________________________Any other medical or surgical complaints: ___________________________________________________________________________

Menstrual History

Menarche: ________ years Cycle: _____/______Flow and regularity: ____________________________________Pap smear done: yes/noContraceptions used by husband/patient: ___________________________________________________________________________ Dysmenorrhea, postcoital bleeding, dyspareunia, intermenstrual bleeding, _________________________________________________ History of Presenting Complaint

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Review of System

General: weakness, fatigue, fever

GIT: loss of appetite, nausea, dysphagia, regurgitation, flatulence, heartburn, vomiting, hematemasis, abdominal pain, abdominal distention, abnormal bowel habit, constipation, diarrhea, abnormal stool, rectal bleeding, incontinence

Resp: hemoptysis, dyspnea, orthopnea, hoarseness, wheezing, chest pain

CVS: dyspnea, paroxysmal nocturnal dyspnea, chest pain, palpitations, dizziness, ankle swelling, limb pain

Endocrine: acne, weight gain, hirsuitism, galactorrhea, hot flushes, night sweats, heat or cold intolerance

UGS: loin pain, poor stream, dribbling, hesitancy, dysuria, urgency, hematuria, polyuria, incontinence, nocturia

CNS: behavioral changes, depression, memory loss, anxiety, tremor, syncopal attacks, loss of consciousness, fits, muscle weakness, sensory disturbances, parasthesias, dizziness, change of smell, vision or hearing, headaches

MSS: muscle aches, bone pain, joint swelling, limitation of joint movement, disturbance of gait, back pain, muscle wasting

Past Medical History

Medical: DM, HTN, MI, stroke, TB, hepatitis, asthma, cancer, DVT, anemia

Surgical: trauma, transfusions, anesthesia complications, previous surgery: ____________________________

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Family History

DM, HTN, MI, stroke, TB, hepatitis, asthma, cancer, twins, congenital anomalies, infertility, prolapse

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Medication History

Current pregnancy: _________________________________________________________________________

Before pregnancy: __________________________________________________________________________

Allergies: __________________________________________________________________________Social History

Smoking, hukka, niswaar, alcoholHousing: ___________________________________

Monthly income: _____________________________Social class: _______________________________________________________________________________________________________________________________________________

Examination

GENERAL AND PHYSICAL EXAMINATION

Appearance: ___________________________________________________________________________________________________

Height: ________________________Weight: ___________________kg

Pulse: ________________________/minBlood pressure: _______ / _______mmHg

Temperature: ________________________Respiratory rate: ___________________/min

Hands: leukonychia, koilonychia, thenar or hypothenar atrophy, sweatiness, splinter hemorrhages, clubbing

Skin: spider angiomata, pallor, rash, petechiae, bruises, capillary refill _________, skin turgor ________ Eyes: both pupils round, regular and reactive, pallor, jaundice

Face: chloasma, jaundice, periorbital edema, proptosis, oral hygiene ______________Neck: normal carotid pulses, tracheal deviation, goiter, engorged neck veins

Lymph nodes: __________________________________________________________________________________________________

Lung: ________________________________________________________________________________________________________Heart: _______________________________________________________________________________________________________GU: non-palpable kidneys, distended bladder, renal punch

Extremities: ankle edema, cyanosis, erythema, varicose veins, peripheral pulses normal, calf tenderness

CNS: cranial nerves _________, sensory or motor loss, tone _________, reflexes __________, neck rigidity

BREAST EXAMINATION

Inspection: ____________________________________________________________________________________________________Palpation: _____________________________________________________________________________________________________Lymph nodes: _________________________________________________________________________________________________Any other: ____________________________________________________________________________________________________ABDOMINAL EXAMINATION

Inspection

Shape of abdomen: _______________________________Scars: _______________________________________________

Umbilicus: _______________________________

Striae gravidarum, linea nigra, visible veins, discoloration, _______________________________________________________________

Palpation

Tenderness: _______________________________Scar tenderness (if previous LSCS): _________________________

Fundal height: _______________________________Lie of fetus: ___________________________________________

Presentation_______________________________Engagement: __________________________________________

Liquor volume_______________________________Estimated fetal birth weight: ______________________________

Auscultation

Fetal heart rate: ______________________________Regular/ Irregular

OTHER EXAMINATION (_____________________________________________________________)

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PELVIC EXAMINATION

Vulva/ Perineum: _______________________________________________________________________________________________

Bleeding:Color _____________________ Amount _____________________

Discharge: Color _____________________ Amount _____________________ Smell _____________________ SPECULUM EXAMINATION

Vagina: _______________________________________________________________________________________________________

Cervix: Appearance_______________________ Dilatation ___________________

Discharge: Color _____________________ Amount _____________________ Smell _____________________

Bleeding: Color _____________________ Amount _____________________

VAGINAL EXAMINATION

Cervical length: _______________________Cervical dilatation: _______________________

Consistency:_______________________Station: ________________________________

Position:_______________________Membranes: Intact/absent/ARM

Liquor (clear/ meconium stained)Amount of liquor: _______________________

BISHOPS SCORE

Parameters

Score

0

1

2

3

Cervical Dilatation

0 cm

1-2 cm

3-4 cm

5 cm

Cervical Length

2 cm

2-1 cm

1-0.5 cm

0.5cm

Cervical Consistency

Firm

Medium

Soft

-

Station

-3

-2

-1 or 0

-

Position of Cervix

Posterior

Central

Anterior

-

Total Bishops Score: _________________________________________________________________________

PELVIC ASSESSMENT

Sacral promontory: _______________________Sacrotuberous ligaments: ______________________

Sacral curve: _______________________Inter-spinous distance: ______________________

Sub-pubic arch: _______________________Inter-tuberous distance: ______________________

Result: ____________________________________________________________________________________________

Differential Diagnosis

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Investigations

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Plan/Treatment

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