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    Obs Case Proforma

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    This document contains a case proforma for an obstetrics patient, including sections for history, physical examination, and provisional diagnosis. The history section includes information on the chief complaints, obstetric formula, medical history, menstrual history, family history, and personal history. The physical examination section outlines examining the mental state, build, decubitus, thyroid, breasts, spine, gait, vital signs, and abdominal examination including inspection, palpation, auscultation, and per vaginal exam. The provisional diagnosis states the patient is a 22 year old primigravida with term gestation and hypertension complicating the pregnancy.

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    Obs Case Proforma

    Uploaded by

    Hero
    130 views1 page
    This document contains a case proforma for an obstetrics patient, including sections for history, physical examination, and provisional diagnosis. The history section includes information on the chief complaints, obstetric formula, medical history, menstrual history, family history, and personal history. The physical examination section outlines examining the mental state, build, decubitus, thyroid, breasts, spine, gait, vital signs, and abdominal examination including inspection, palpation, auscultation, and per vaginal exam. The provisional diagnosis states the patient is a 22 year old primigravida with term gestation and hypertension complicating the pregnancy.

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    Obstetrics case performa

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    This document contains a case proforma for an obstetrics patient, including sections for history, physical examination, and provisional diagnosis. The history section includes information on the chief complaints, obstetric formula, medical history, menstrual history, family history, and personal history. The physical examination section outlines examining the mental state, build, decubitus, thyroid, breasts, spine, gait, vital signs, and abdominal examination including inspection, palpation, auscultation, and per vaginal exam. The provisional diagnosis states the patient is a 22 year old primigravida with term gestation and hypertension complicating the pregnancy.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    130 views1 page

    Obs Case Proforma

    Uploaded by

    Hero
    This document contains a case proforma for an obstetrics patient, including sections for history, physical examination, and provisional diagnosis. The history section includes information on the chief complaints, obstetric formula, medical history, menstrual history, family history, and personal history. The physical examination section outlines examining the mental state, build, decubitus, thyroid, breasts, spine, gait, vital signs, and abdominal examination including inspection, palpation, auscultation, and per vaginal exam. The provisional diagnosis states the patient is a 22 year old primigravida with term gestation and hypertension complicating the pregnancy.

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    Obstetrics CASE PROFORMA PHYSICAL EXAMINATION

    Name, Wife of, Age, Booked/Not Booked, Address, Education, -Mental state and intelligence (CCC)
    Occupation, Income, Marital Status, Years of Marriage, -Build, state of nutrition
    Literacy Status, Religion, Socioeconomic Status -Decubitus and Attitude, Any facies
    HISTORY Check Thyroid enlargement, Breast, spine and gait.
    [A __ year old patient, supine decubitus who is __ built __
    Chief Complaints: nourished is conscious, coherent, cooperative, and
    -This lady was admitted for safe institutional delivery in view of comfortably seated/lying on the bed, well oriented to time,
    previous CS (For Previous LSCS Case) place and person]
    -Difficulty in breathing, palpitations, chest pain etc since (for heart There is No Pallor, Icterus, cyanosis, koilonychias,
    disease complicating pregnancy) generalised lymphadenopathy and no pedal edema.
    -This lady was admitted for safe institutional delivery in view of VITALS: Temperature: Pulse, RR, BP.
    Increased Blood pressure (for PIH case)
    -This lady was admitted for safe institutional delivery in view of LOCAL EXAMINATION-ABDOMEN
    Twin pregnancy
    After taking informed consent, patient is in supine position
    -Breathless, palpitations, weakness, fatigue, edema (in case of
    with arms by the side of her body.
    Anaemia complicating pregnancy)
    INSPECTION:
    History of Present Illness:
    Distention, Skin noticed for striae gravidarum and linea
    Obstetric Formula
    albicans/nigra, Umbilicus, All quadrants move equally with
    LMP, EDD, Mode of conceiving
    respiration, Previous Caesarean scars, any visible pulsations
    If primi ask how many years after marriage
    or engorgement of veins, Hernial orifices
    UPT done at ________ in _____ months of amenorrhea and
    confirmed with a scan at ____ gestational age.
    PALPITATION: Consent taken and then Fundal height (in
    First Trimester
    weeks), Fundal grip (Soft, Non ballotable, Broad mass
    Nausea, Vomiting, Morning Sickness, Discharge/Bleeding per
    probably podalic pole) , Lateral grip [Left side hard board
    vagina, Increased frequency of micturition, Burning micturition,
    like mass felt probably baby’s back & On right side multiple
    Pain abdomen, Fever with or without rashes, Tetanus Toxoid, Folic
    fetal parts felt], First Pelvic Grip [hard ballotable, mass
    Acid Tablets, Teratogenic drug usage, Scan – Dating scan and
    probably cephalic pole] Second Pelvic Grip.
    Nuchal Translucency scan, Exposure to X-Ray
    AUSCULTATION: Along the spinoumblical line on the side of
    Second Trimester
    the spine
    Time of onset of Quickening, Discharge/Bleeding per vagina,
    Per Vaginal Examination – NOT done
    Infections/ Fever/ Rashes, Folic acid and Iron Tablets, Pedal
    Edema, Calcium Tablets, Tetanus Toxoid, TIFFA [Targeted imaging
    OTHER SYSTEMS:
    for foetal anomalies] scan,
    CVS- Normal S1 S2 heard, No murmurs.
    Third Trimester
    Respiratory: BLAE + Normal vesicular breath sounds, No
    Continued perception of quickening and its frequency, Discharge/
    adventitious sounds
    Bleeding per vagina, Burning micturition, Pedal edema, Folic acid,
    CNS- No Facial asymmetry, all reflexes are normal
    Iron, Calcium tablets, Frequency of Antenatal check-ups, Scans
    PROVISIONAL DIAGNOSIS:
    A 22 yr Old Primi with term gestation with fundal height
    PAST HISTORY: corresponding with gestational age with Hypertension
    Past Obstetric History with the outcome, and development history complicating pregnancy, With No signs of imminent
    and immunization history of each child eclampsia
    -Any H/O HTN, DM, CAD ,TB, Hypo/Hyperthyroidism/ Epilepsy/ A 25 yr old Pregnant women with G3P2L1 came with
    Asthma/COPD/ / Blood transfusions uncomplicated breech presentation for safe institutional
    Past Medical & Surgical History delivery

    Drug and Treatment History: H/O previous surgery for breast NOTES:
    Marital History:
    Years of marriage, Consanguinity, Husband living with patient or
    not, Contraception, Infertility

    FAMILY HISTORY:
    None of the patient’s parents, siblings or first degree relatives have or
    have had similar complaints or any significant co morbidities.
    Any H/O twins, congenital anomalies.

    Menstrual History: Age of menarche, Duration of cycle, Bleeding


    – regular/ heavy/ less, Passage of clot, number of pregnancies,
    breast feeding, LCB, use of HRT/contraceptives

    PERSONAL HISTORY: [Important]


    Diet, Appetite, Bowel, Bladder, Sleep, Addictions (Alcohol and
    Smoking), Any Allergies, BLOOD GROUP

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