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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: __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
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: ____________________________
__________________________________________________________________________________________
Family History
DM, HTN, MI, stroke, TB, hepatitis, asthma, cancer, twins, congenital anomalies, infertility, prolapse
__________________________________________________________________________________________
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 (_____________________________________________________________)
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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
_________________________
_________________________
_________________________
_________________________
Investigations
_____________________
_____________________
___________________
_____________________
_____________________
Plan/Treatment
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________