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Swapneel Shah
History taking
1.
2.
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5.
6.
Name
Age
GPLAD
Active married life of
Occupation
Residence
7. Months of amenorrhea
8. Chief complaints
9. ODP
a. Ward course
b. Treatment given
c. Symptoms increased, decreased
d. Negative history
e. Rule out PIH, GDM, heart disease
i. History of headache, visual disturbances
ii. History of palpitations, chest pain, hemoptysis
b.
c.
d.
e.
f.
g.
h.
i.
Swapneel Shah
1. Amenorrhea period
2. Spontaneous abortion/live birth
a. Dilatation and Curettage done or not?
3. Hydramnios?
4. Premature delivery?
Weeks of gestation
Conception spontaneous/any treatment
UPT done?
USG done?
ANC registration
Medications, hematinics, calcium
i. If yes, how long?
Tetanus toxoid
Exposure to radiation (?)
General examination
1. Conscious, cooperative, well-oriented
2. Built, nourishment- good/average/poor
3. Temp, pulse, RR, BP
4. Height
5. Weight
6. Gait
7. Pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
8. Platynychia, koilonychia
9. Glossitis, angular stomatitis
10. Thyroid swelling, JVP
21/09/2012
Swapneel Shah
Obstetric examination
1. Inspection
a. Swelling- globular/pyriform
b. Linea nigra, stria gravidarum, linea albicantes seen/not seen
c. Umbilicus vertically/transversely stretched/everted? hydramnios/plural
pregnancy
d. Scars/sinuses
i. If present, position- vertical/midline/pfannenstiel
ii. Healing- well healed/keloid formation
2. Palpation
a. Clinical presentation of uterine size is _____ weeks (Bartholomews rule of fourths)
b. Fundal height is _____ cm measured along the contour of the uterus from pubic
symphysis after correction of dextrorotation of the uterus
c. Therefore, by MacDonalds rule, gestational age in weeks= 8/7 x fundal height.
3. Leopolds manoeuvres
a. Fundal grip
i. Firm, irregular, non-ballotable mass corresponds to fetal breech
b. Right lateral grip
i. Continuous board like resistance corresponds to fetal back
c. Left lateral grip
i. Multiple knob like structures which slip under the fingers on deep palpationfetal limbs
d. Pawliks first grip
i. Hard, globular, ballotable, non-ballotable- fetal head- floating or engaged
e. Deep pelvic grip (Pawliks second grip)
i. Convergence or divergence of fingers
4. Auscultation
a. Fetal heart sounds inside/outside the left spino umbilical line
b. Rhythm- regular or not.
c. Rate- ____ bpm
Breast examination
1. Development normal or not
2. Nipple and areola- normal or not
a. No cracks, fissures or retracted nipple
b. No abnormal nipple discharge
c. No abnormal lump palpable
Respiratory system/Cardiovascular system
1. Breath sounds normal- whether rales/rhonchi are present
2. Heart sounds normal- no murmurs
Gastrointestinal examination
1. Liver/ spleen palpable/could not be felt because of enlarged uterus.
Diagnosis
21/09/2012
Swapneel Shah
Mrs ____, age _____, GPLAD, comes with _____months of amenorrhea with _____ weeks size uterus with
a single live fetus in longitudinal lie, flexed attitude, cephalic presentation, ______ as the presenting
part, which is floating/ engaged with medical/obstetric diagnosis e.g.________
Investigations
1. Hemoglobin
2. Blood grouping- give anti-D if required
3. HIV-ELISA
4. VDRL
5. Malformation scan- 18 to 20 weeks
6. FBS/PLBS
7. TT neonatal tetanus
8. Urine- sugar and protein
9. HBsAg
10. TSH- if increased, do free T3, T4.
21/09/2012