Professional Documents
Culture Documents
CASE STUDY
FORMAT
SUB- OBSTETRICS AND GYNECOLOGY
SUBJECT :
TOPIC :
SUBMITTED TO :
SUBMITTED BY :
COLLEGE NAME :
SIGNATURE OF SUPERVISOR :
DATE :
SELF INTRODUCTION:-
PATIENT INTRODUCTION:-
IDENTIFICATION DATA:-
Name: :
Age :
Sex :
I.P No :
Ward :
Hospital :
Address :
Marital status :
Educational status :
Occupational status :
Husband name :
Nationality :
Religion :
Date of admission :
Diagnosis :
Obstetrical score :
OBSTETRICAL HISTORY:-
OBSTETRIC SCORE :
LMP :
EDD :
POG :
Patient had a significant past obstetric history, patient had one female child with normal
delivery.
ANTENATAL CARE:-
MENSTRUAL HISTORY:-
FAMILY HISTORY:-
FAMILY COMPOSITION:-
FAMILY TREE:-
SOCIO ECONOMIC DATA:-
PERSONAL HISTORY:-
Immunization :-
Smoking :-
Alcoholism :-
Use of drugs :-
Hobbies :-
NUTRITIONAL PATTERN:-
ELIMINATION PATTERN:-
PERSONAL HYGIENE:-
INVESTIGATION CHART:
Following investigations were done for the patient:
TREATMENT CHART:
2. Temperature
3. Pulse
4. Respiration
General assessment:
Appearance :
Body built :
Sensorium :
Emotional state :
Posture :
Body odor :
Breath :
Weight :
Height :
SKIN CONDITION:
Skin color :
Skin lesions :
Temperature :
Texture :
Turgor & elasticity :
Edema/ puffiness :
Hyperpigmentation of : areola nevi
Linea nigra
Chloasma
Hair:
Color :
Distribution :
Nails:
Hygiene :
Condition :
Angle of nail beds :
Nail bed color :
Head & face
Shape :
Facial appearance :
Cyanosis :
Tenderness :
Eyes:
Eye brows :
Eye lashes :
Eye lids :
Eye Shape, appearance :
Sclera :
Cornea :
Pupils :
Vision :
Ears:
Position :
Shape & size :
Tympanic membrane :
Hearing :
Discharge :
Nose:
External nose
Size :
Shape :
Internal nasal mucosa :
Mouth:
Lips
Color :
Shape :
Condition :
Teeth :
Gums :
Tongue :
Oropharynx :
Tonsils :
Uvula :
Palate :
Neck
Range of motion :
Thyroid :
Lymph node :
Heart :
:
Breast
Shape :
Lump :
nipple :
Abdomen:
(i) Inspection:
Skin changes :
Lesions :
Size :
Umbilicus :
(ii) Palpation:
Fundal
Fundal height :
Abdominal girth :
Lateral
Fetal lie :
Pelvic
Presentation :
Presenting part :
(iii) Auscultation:
Perineum : os -
cx-
membrane-
pelvis-
station-
Genitalia:
Rectum :
Female genitalia :
Back:
Vertebral column :
Joints :
Extremities:
(i) Upper extremities :
Range of motion :
Syndactyl :
Polydactyl :
Oedema :
DISEASE CONDITION:
TYPES :-
CAUSES:-
CLINICAL MANIFESTATION
DIAGNOSTIC EVALUATION
MEDICAL MANAGEMENT
SURGICAL MANAGEMNT
DIETARY MANAGEMNT
NURSING MANAGEMENT
NUSRING DIAGNOSIS
HEALTH EDUCATION
RESEARCH IMPLEMENTATION
SUMMARY
CONCLUSION
REFERENCES