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COMPLAIN: ANC (High Low risk) – with medical disorder

APPROACH DIAGNOSIS: G P + & Wks. (Spont. ART), previous cs.

Married ( ) Mons. Yrs. Ago
Living Children ( ) preterm ( ) Ectopic ( ) Miscarriages ( )
Delivery mode: Vaginal Births () C-Sections ( )
Last delivery: by VD CS ( ) yrs. Mons. Ago at Hospital
LMP: / / 202 EDD: / / 202
Complications of previous pregnancy or delivery: None
MEDICALLY: free SURGICALLY: free
Medications:
Current:
Past:
Requested Investigations:

Pregestational - Gestational D.M. (Controlled uncontrolled) on:

 Insulin () morning and () evening
 Oral medication
 Diet
Hypothyroidism (Controlled uncontrolled) on:
Hypertension : (Controlled uncontrolled) on:
 Aldomet 2*3
Allergy to:
US: SVIUF

Presentation: Cephalic G. Age:

BPD: 34 wks. 2 d. FL: 34wks. 2 d.

AC: 33 wks. 3 d. F.Wt: 2290 gm.

AF: average Placenta: posterior

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COMPLAIN:
APPROACH DIAGNOSIS:

P+ & Married ( ) mns. Yrs. Ago.

LMP: 26 / 06 / 143 REGULAR / IRREGULAR ( / )

* Dyspareunia: * DYSMENORRHEA: * VAG. DISCHARGE:

Contraceptive:
MEDICALLY: free SURGICALLY: free
…………………………………………………………………………………………………………………………
Folliculometry: RT. OVARY: Follicles (2’’11mm) LT. OVARY: Follicles (4, 11-12mm)

Endometrial thickness: 0.74 mm

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PLANNED FOR:

PID TREAT.

OV. INDUCTION

HSG

HORMONAL PROFILE

SERIAL B-HCG + US.

DM HYPETENSION HYPOTHYRODISM
Menstrual History:
PO+O
First day of last menstrual: \ \ 201 (?? 2 mns. ago)
Irregular bleeding 5yrs. ago—NORMAI HB%
Controlled with hormonal ttt. Then recure 2mns after stopping ttt
Pt. is divorced now(married twice)
No compliance with pills treatment
History of dyspareunia
Nodules in recto-vaginal septum
FOR : D&C bibpsy then vissane for 9mns.

Contraceptive and Sexual History:

Present birth control method:NON

Birth control methods used in the past:

METHOD LENGTH OF USE REASON FOR DISCONTINUATION
1) P

2) PILLS 2 MS

Do you experience pain or discomfort with sexual intercourse? Yes No

Gynecological History:
Have you been vaccinated for Human Papilloma Virus (HPV) – Gardasil Yes No

Last Pap Smear Last Mammogram Last Bone Density (DEXA)

Have you ever been on hormone therapy (estrogen / progesterone)? Yes No

Any personal history of: Abnormal Pap Smears Yes No

Sexually transmitted diseases Yes No

Fibroids Yes No

Endometriosis Yes No

Infertility Yes No