Pocket Manual to Case Taking Ravinder Nath Bansal
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Obstetrics1

 
PROFORMA
Name…………Age………Address…………
W/o…………………………………………
Occupation…………………………………
Socioeconomic status………………………
Obstetric score— G P L A.
LMP………………………
EDC………………………
Gestational age……………
 
PRESENTING COMPLANT
2
 
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
  • Hypertension (Headache)3
  • 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 period of infertility (any trt.)4
  • Any contraceptive use
  • Previous children
    1. Age at present
    2. Wt. at birth
    3. Term/preterm
    4. Asso. complications (DM, PIH)
    5. 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………………
  • Gait, Breast, Thyroid5
  • 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
  • Umbilicus everted/ not6
 
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.