Identifying Data:

Patients initials, Age, Gravidity and Parity (OBscore), Marital status, Religion, occupation, Address, Date
and Time of History taking

Reliability:

Chief Complaint:

HPI: LMP:AOG:EDC, fetal movement, Danger signs of pregnancy if present/absent

Antenatal History: Date of confirmation of pregnancy, AP care: (date of consult, place, with whom,
diagnostic tests, illnesses/treatment during AP care; First trimester:Second trimester.Third
trimester.Immunizations:, Exposure to teratogens/communicable diseases

PMH: Illnesses ( include present medications), Surgeries ( procedure, date, place, complications ,Allergies
,History of Blood transfusion

Fam HX: HPN,Hematologic disease, DM, Malignancies, Thyroid disease, Heart disease, Asthma, allergies

Personal Social: Smoking, Alcohol intake, Illicit drug use, Educational attainment, Lifestyle / home safety (
if applicable)

OB HX:

Gravidity Year Manner of Delivery Place Birth Attendant Fetal Outcome

G1 2002 NSD ARMMC OB No Complications

G2 2006 NSD Home Traditional Midwife No Complications

Menstrual HX: Menarche: Interval,Duration,Amount, Symptoms

Sexual Hx: Coitarche, # of sexual partners, HX of STI

Gyne Hx: papsmear, use of contraception, hx of immunizations

ROS:

PE:

General survey:

Vital signs: BP:, CR, RR, Temp, Weight, Height

SKIN:

HEENT

Neck:

Breast:

Chest/ Lung findings:

Heart:

Abdominal exam

Inspection

Leopolds maneuver

LM1

LM2

LM3

LM4

Fundic Height

Fetal Heart tones

Extremities

Neurologic Exam ( if applicable

Assessments:

e.g. G P (OB score), Pregnancy Uterine_____ weeks age of gestation by LMP or UTZ, presentation,
labor/not in labor, other medical problems, include other surgical procedures

DDX:

Plan of mgt: diagnostic, therapeutic

Discussion: Discuss how you came up with your diagnosis

Rule in/ rule out differentials (if applicable)

Justify plan of management

Discuss the disease entity

BUT ALWAYS CORRELATE DISCUSSION WITH THE PATIENTS CONDITION (PATIENTS HISTORY AND P.E.) !!!!

FORMAT:

A4 Paper

Arial font, size 12

1.5 space