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Gravidity Year Manner of Delivery Place Birth Attendant Fetal Outcome

This document contains a template for documenting a patient's obstetric history and examination. It includes sections for identifying data, reliability, chief complaint, history of present illness, antenatal history, past medical history, family history, personal/social history, obstetric history, menstrual history, sexual history, gynecologic history, review of systems, physical examination findings, assessments, differential diagnoses, and plan of management. The physical exam section includes vital signs, skin, head/eyes/ears/nose/throat, neck, breasts, chest/lungs, heart, abdomen, extremities, and neurologic exam.

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Ruth Galera
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52 views3 pages

Gravidity Year Manner of Delivery Place Birth Attendant Fetal Outcome

This document contains a template for documenting a patient's obstetric history and examination. It includes sections for identifying data, reliability, chief complaint, history of present illness, antenatal history, past medical history, family history, personal/social history, obstetric history, menstrual history, sexual history, gynecologic history, review of systems, physical examination findings, assessments, differential diagnoses, and plan of management. The physical exam section includes vital signs, skin, head/eyes/ears/nose/throat, neck, breasts, chest/lungs, heart, abdomen, extremities, and neurologic exam.

Uploaded by

Ruth Galera
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Identifying Data:

Patients initials, Age, Gravidity and Parity (OBscore), Marital status, Religion, occupation, Address, Date
and Time of History taking

Reliability:

Chief Complaint:

HPI: LMP:AOG:EDC, fetal movement, Danger signs of pregnancy if present/absent

Antenatal History: Date of confirmation of pregnancy, AP care: (date of consult, place, with whom,
diagnostic tests, illnesses/treatment during AP care; First trimester:Second trimester.Third
trimester.Immunizations:, Exposure to teratogens/communicable diseases

PMH: Illnesses ( include present medications), Surgeries ( procedure, date, place, complications ,Allergies
,History of Blood transfusion

Fam HX: HPN,Hematologic disease, DM, Malignancies, Thyroid disease, Heart disease, Asthma, allergies

Personal Social: Smoking, Alcohol intake, Illicit drug use, Educational attainment, Lifestyle / home safety (
if applicable)

OB HX:

Gravidity Year Manner of Delivery Place Birth Attendant Fetal Outcome

G1 2002 NSD ARMMC OB No Complications

G2 2006 NSD Home Traditional Midwife No Complications

Menstrual HX: Menarche: Interval,Duration,Amount, Symptoms

Sexual Hx: Coitarche, # of sexual partners, HX of STI


Gyne Hx: papsmear, use of contraception, hx of immunizations

ROS:

PE:

General survey:

Vital signs: BP:, CR, RR, Temp, Weight, Height

SKIN:

HEENT

Neck:

Breast:

Chest/ Lung findings:

Heart:

Abdominal exam

Inspection

Leopolds maneuver

LM1

LM2

LM3

LM4

Fundic Height

Fetal Heart tones

Extremities

Neurologic Exam ( if applicable


Assessments:

e.g. G P (OB score), Pregnancy Uterine_____ weeks age of gestation by LMP or UTZ, presentation,
labor/not in labor, other medical problems, include other surgical procedures

DDX:

Plan of mgt: diagnostic, therapeutic

Discussion: Discuss how you came up with your diagnosis

Rule in/ rule out differentials (if applicable)

Justify plan of management

Discuss the disease entity

BUT ALWAYS CORRELATE DISCUSSION WITH THE PATIENTS CONDITION (PATIENTS HISTORY AND P.E.) !!!!

FORMAT:

A4 Paper

Arial font, size 12

1.5 space

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