medical notes

Apr 17th, 2015
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HISTORY TAKING &PHYSICAL EXAMINATIONOBGYNDR. SALWA NEYAZIASSISTANT PROF. & CONSULTANT OBSTETRICIANGYNECOLOGISTPEDIATRIC & ADOLESCENT GYNECOLOGISTOBSTETRIC HISTORY1-General informationName, age , gravidity, parity, LMP, EDD (Naegeles rule)Gravidity no. of pregnancies including currentpregnancy (regardless of the outcome N or abortion)Parity no. of births beyond 24 wk gestation2-Current problem/ complaint3-History of current complaint4-History of current pregnancy details of the 1st ,2nd & 3rd trimesterlab tests & U/S scanspatternOBSTETRIC HISTORY5-Menstrual & gynecological historyLMP details ( was it conform to the usual in terms oftiming, volume, and appearance)Regular or irregular cyclesLength of the cycleOCPSurgical proceduresHx of infertilitySexually transmitted diseasesUterine anomaliesOBSTETRIC HISTORY6-Past obstetric history Outcome of previous pregnancies in details includingthe abortions Any significant antenatal, intrapartum or postpartumevents Previous maternal complications Mode of delivery B Wt Life & health of the babyOBSTETRIC HISTORY7-Past medical/ surgical HxSome medical conditions may have impact on the course of thepregnancy or the pregnancy may have an impact on the medicalcondition examples:Heart diseaseHypertensionDmEpilepsyThyroid diseaseB asthmaAny previous surgery.

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