Escolar Documentos
Profissional Documentos
Cultura Documentos
1) Patient Profile
Name
RN:
Age
Bed:
Race
Religion
Gravida
Parity
Abortion
LMP
EDD
POA
Residence
Occupation
Admitted date
2) Chief complaint + Duration
Pd
Dd
s/s
Severity
Medication
Risk factors
Causes
Remarks
Investigations
Height
Weight
Hb
Urine routine
Bloog group
BP
MOGTT
Hept. B
HIV
VDRL
Height
Weight
BP
Weight
BP
Uterine size
Quickening
MOGTT
Ultrasound (Anomaly
scan)
Development of illness
Nuchal thickness :
Tetanus toxoid
Medications
Remarks
3rd trimester
Minor ailment
Bleeding
Height
Physical Examination
MOGTT
Ultrasound
Remarks
Uterine size
Year
Type of labour
(SVD, LSCS,
Vacuum, etc...)
Pregnancy
(Full / Pre)
6) Menstrual history
Menarche
:
Menstrual cycle
: Regularity
Antenatal period
complication
: Regular / Not
Duration of flow
Cycle length
Contraceptive History :
7) Gynaecological history
History of suggestive STI
Family history
:Maternal
Paternal
Siblings
8) Personal history
Diet history
Sleep
Social history
: Marital status :
Drug history
Spouse
Occupation
Education
Income
Basic needs
:
Any allergic (
)
Traditional Medication (
Smoking/Alcohol
Others
Health of baby
(G, Weight,
A/D)
Breast
Feeding
Remarks
Physical examination
General examination
Remarks
Built
Nourishment
Thin / obese
BMI
Weight:
Height:
Vital parameters
BP
Eyes
Pallor
Temp
Icterus
Pallor
Mouth
Icterus
Oral hygiene
Thyroid enlargement
Finger clubbing
Nail colour
Koilonychia/ platynychia
IV Cannula / IV fluid
Breast
Leg
Varicose vein
Edema
Remark
Systemic examination
1) Cvs
: Pulse rate
Heart rate
Heart murmur
Blood pressure
Heart beat
2) Respi
: Respiratory rate
Breathing
:
:
Abdominal examination
1) Inspection
I.
II.
III.
Stretch mark
a. Stria gravidarum
b. Stria albicans
IV.
Scars :
site
Size
Healing
Hernia to scar :
V.
Umbilicus
VI.
Fullness of flank
VII.
Fetal movement
VIII.
Quadrant movement
Inverted (
Everted (
2) Palpation
I.
Enquire of pain
II.
Superficial palpation
III.
IV.
Leopolds maneuvers
a) Fundal grip
A. Fetal Head Hard globular mass / Hard globular mass which is ballotable suggestive of fetal head.
B. Fetal Breech Broad smooth irregular mass suggestive of fetal breech.
C. Fetal Back Smooth curved broad surface suggestive of fetal back.
D. Fetal Limbs Small irregular knob like sturcture suggestive of fetal limbs.
Discussion:
Remarks: