QMMC: OB-GYN OPD

Date: August ____, 2019 Time: ___ : ___ AM / PM

Name: Age: Birthday: ___ / ___ / ______ AOG: _______ w _____ d
OB History PNCU:
st
☐ Vaginal bleeding LMP: ___ / ___ / ______ 1 trimester: 0-28 weeks every ___ weeks
nd
☐ Watery vaginal discharge M: ___ y/o 2 trimester: 29-36 weeks every ___ weeks
rd
☐ Uterine contractions I: Every ___ days 3 trimester: >36 weeks every ___ week/s
☐ Fetal movement D: ___ days
A: ___ ppd, ______ soaked
S: ( ) Dysmenorrhea
Physical Exam: Medications:
Fundic Height: ___ cm Speculum: IE: ☐ Prenatal multivitamins 1 tab OD
FHT: ___ bpm ☐ FeSO4 1 tab OD
☐ Calcium tablet, 1 tab TID

Diagnostics: Ultrasounds: Plan:

☐ CBC w/ Platelet Count Date: Date:
☐ HIV SLIUP, ___ w ___ d SLIUP, ___ w ___ d
☐ VDRL Presentation: Presentation:
☐ HBsAg EFW: EFW:
☐ TVS / PUS AFI: AFI:
Placenta: Placenta:
☐ Urinalysis
BPS: ___ / 8 BPS: ___ / 8
☐ 75-g OGTT
FHT: FHT:
Diagnosis:
G___P___ ( ___ ___ ___ ___ ), Pregnancy uterine, _______ weeks AOG by _____, __________ in labor*

NOTES:

10 Danger Signs:
1. Epigastric/RUQ pain, 4. Vaginal bleeding/spotting 8. Prolonged vomiting
2. No/decreased fetal movement (normal is >10 5. Watery vaginal discharge 9. Fever
in 2h) 6. Headache 10. Nondependent edema
3. Dysuria 7. Blurring of vision

!!! If BP ≥ 140/90, repeat after 15 mins, refer

PNCU: Ultrasounds:
0-28 weeks every 4 weeks TVS <12 weeks
29-36 weeks every 2 weeks PUS >12 weeks
>36 weeks every week

CBC: UA:

*Diagnosis:
- AOG: by LMP / EUTZ (<20 weeks) / LUTZ (>20 weeks)
- If CS, write year/s & indication/s
- Reasons for CS: Dystocia, malpresentation, uncontrolled HPN, non-reassuring fetal status, placenta previa, fetal macrosomia
- Insert comorbids