Obstetric sheet…./…..

/……

Personal history: Husband history:

Name: Name:
Age : Age:
Address: Occupation:
Marital status: Special habits:
Occupation: BG:
Education : Consanguinity:
Gravidity and parity:
Special habits:
BG:
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Data of admission:

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Chief complain:
Patient with amenorrhea of pregnancy since:
Came to the ER/OPC complaining of:……..
Since:………

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History of present illness:
GA: LMP: EDD:
Planned / unplanned/ precious pregnancy:
How she know that she become pregnant:

Is there ANC : Regular? How many?

Is she complaining of any chronic illness:
Analysis of the chief complaint:
Until today
 Obstetric sheet…./…../……

Analysis of the current pregnancy:

1st trimester:
GIT: nausea, vomiting, constipation, heart burn,
UT: increased frequency, dysuria ,
CVS: palpitation, dyspnea, orthopnea, postural hypotension, dizziness,
BREAST: enlargement, tenderness.

ABNORMAL:
Hyperemesis gravidarum: excessive vomiting causing dehydration.
Vaginal bleeding------→abortion, vesicular mole, ectopic,
Vaginal discharges------------→infection,
Fever, dysuria, loin pain------------→pyelonephritis.

2nd trimester:
Alleviation of 1st trimester symptoms
Quickening at:…………………………………..normally(16-18wks in MG and 18-20wks in PG)
Progressive abdominal enlargement

DISORDERS in 2nd trimester:

Preeclampsia (LL edema., blurred vision, headache, epigastric pain)
Placenta previa(bleeding)
PROM (gush of fluid)
DM (polydepsia, polyphagia, polyuria)
HF (palpitation, dyspnea, LL edema)
Pyelonephritis (fever, dysuria, loin pain).

3rd trimester:
Lightening
↑frequency of micturation
↑ fetal kicks, uterine contractions.
DISORDERS AS IN 3ND TRIMESTER.
Preeclampsia (LL edema., blurred vision, headache, epigastric pain)
PROM (gush of fluid)
DM (polyuria, polydepsia, polyphagia)
HF (palpitation, dyspnea, LL edema)
Pyelonephritis (fever, dysuria, loin pain)
Bleeding … pl. previa, abruption.
 Obstetric sheet…./…../……

Systemic Review:
General symptoms
• Weight change (loss or gain), change in appetite (loss or gain), fever,
malaise, night sweating.
Neurological symptoms
Altered sensory, motor, consciousness, behavior, or coordination.
Ocular disturbances: blurred vision, or field defect.
Convultions.
Fever.
Cardiovascular symptoms
• dyspnea, orthopnea, paroxysmal nocturnal dyspnea, chest pain,
palpitations, ankle swelling, claudication.
Respiratory symptoms
• Cough, dyspnea, hemoptysis, sputum, wheeze, chest pain.
Gastrointestinal symptoms
• Dysphagia, indigestion, heartburn, hematemesis, abdominal pain,
distention, nausea, vomiting, constipation, diarrhea, rectal blood loss,
melena, jaundice.
Genitourinary symptoms
• Urinary frequency, dysuria, urgency, polyuria, oliguria, anuria,
nocturia,lin pain , hematuria, pneumoria, incontinence.
Musculoskeletal symptoms
• Muscle or joint pains, stiffness, swelling, bone ache.
Skin symptoms
• rashes, itch, nail change, ulcers, hair loss or gain.
Hematological: dyspnea, palpitation, fainting, bleeding, fever,
thrombosis.
Endocrine symptoms:
Hypothyroidism: fatigue, tiredness, weakness.
Hyperthyroidism: hyperactivity and irritability.
Hot or cold intolerance,
excessive sweating, thirst or hunger,
altered face appearance, glove or shoe size.
Weight loss or gain, hirsutism, galactorrhea, flushing.
 Obstetric sheet…./…../……

Obstetric history: G: P: +
G 1 2 3 4 5 6
DATE/BEFORE
DURATION
PLACE of D
MODE
OUTCOME:
Sex
Number
Health status
VACCINATION
LACTATION
NOW IS

Menstrual history:
Age of menarche:……………………………………
Regularity :………………………………………………
Length of cycle:………………………………………..
Duration:…………………………………………………. Amount:…………………………………..
IMB:…………………………………………………………
Dysmenorrhea:…………………………………………………………………………………………….

Contraceptive history:
Form:……………………………………………………………
Duration:……………………………………………………..
When stop and why:…………………………………………………………………………………………

Past medical history:

Similar condition
Chronic illness as HTN, DM, Epilepsy, TB, asthma, liver disease, malignancy, renal disease,
Congenital anomalies
Radiation exposure
Food or drug allergy

Past surgical history:

Past blood transfusion:

Number
Date
Amount
 Obstetric sheet…./…../……

Family history:
Similar condition
Chronic diseases and tropical illnesses
Congenital anomalies
consanguinity

social:
Community: urban, rural.
Income:

House:
Ventilation
Animal contact:. Yes no
Electricity:. Yes no
Sanitation:. Good bad
Water supply:. Good bad

WALEED