PROFORMA
Name…………Age………Address…………
W/o…………………………………………
Occupation…………………………………
Socioeconomic status………………………
Obstetric score— G P L A.
LMP………………………
EDC………………………
Gestational age……………
PRESENTING COMPLANT
HISTORY OF PRESENT ILLNESS
- First visit to doctor
- Frequency of visits
- TT injections
I TRIMESTER
- Morning sickness
- Bleeding/discharge PV
- Abdominal. Pain
- UTI (Burning micturation/dysuria)
- Tiredness/fatigue
- Excessive salivation
- Iron and folic acid intake
- Drug intake, X-ray, fever (rubella, TORCH)
- Wt. gain per week.
II TRIMESTER
- Bleeding/discharge PV
- UTI (Burning micturation/dysuria)
- Edema—relieving by rest/not
- Quickening—which week.
- Abdominal pain
- Sudden increase/decrease in weight
- Iron and folic acid intake
- Drug intake, X-ray, fever, rubella
- Ultarsound
III TRIMESTER
- Bleeding/discharge PV
- UTI (Burning micturation/dysuria)
- Edema—relieving by rest/not
- Fetal movements Y/N
- Hypertension (Headache)
- Sudden increase/decrease in weight
- Iron and folic acid intake
- Drug intake, X-ray, fever, rubella
MENSTRUAL HISTORY
- Menarche, periodicity (e.g.,– 4/28)
- Menorrhagia/dysmenorrhea
- LMP
MARITAL AND OBSTETRIC HISTORY
- Age at marriage
- Consanguineous Y/N
- Any contraceptive use
- Previous children
- Age at present
- Wt. at birth
- Term/preterm
- Asso. complications (DM, PIH)
- Any congenital anomalies
PAST HISTORY
- Polio, rickets
- Diabetes, hypertension, rheumatic fever
- Jaundice
- Surgery
PERSONAL HISTORY
- Sleep, appetite, addiction
- Bowel, bladder
FAMILY HISTORY
- Congenital anomalies, diabetes
- Hypertension, multiple pregnancy
GENERAL EXAMINATION
- Ht…………Wt………………
- Built and nourishment
- Pallor
- Cyanosis, Clubbing, Jaundice
- Edema: site _____leg/medial malleolus
- Lymphadenopathy
- JVP
- Vital signs:
- Pulse → rate, rhythm, volume, character, peripheral pulses
- BP in Rt. Upper arm in supine position
- Respiratory rate
- Temperature (98.4°F)
OBS. EXAMINATION
INSPECTION
- Abd. transversely/ longitudinally distended
- Flanks full Y/N
- Any undue distention
- Striae gravidarum
- Linea nigra
PALPATION
- Quantity of liquor
- Fundal height—don't mention in cm— say FH corresponds to ………weeks of gestation with flanks full/ not
- Fundal grip
- Umbilical grip
- 1st pelvic grip
- 2nd pelvic grip
- Ballotment
PERCUSION (do not mention, only few teachers may ask)
- Adequacy of amniotic fluid
AUSCULTATION
• FH- | site |
rate | |
rhythm |
DIAGNOSIS
Age, gravida, gestational age, coming with ……… presentation in ……….position. Head engaged/ not and ……‥complicating pregnancy.