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  • Clinical Approach To The Patient: Always Listen To The PT They Might Be Telling You The Diagnosis

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    wardo adam
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    This document outlines the components of an obstetrics and gynecology case history and physical examination. It includes sections to document personal data, present complaint, present illness, obstetric history, menstrual history, medical history, surgical history, drug and allergy history, family history, social history, contraceptive history, sexual history, laboratory tests, differential diagnosis, suspected diagnosis, final diagnosis, management, physical examination including general appearance, vital signs, BMI, and general examination of head, eyes, ears, nose, throat and neck. The goal is to obtain a comprehensive history and perform an examination of the patient to reach an accurate diagnosis and develop an appropriate management plan.

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    This document outlines the components of an obstetrics and gynecology case history and physical examination. It includes sections to document personal data, present complaint, present illness, obstetric history, menstrual history, medical history, surgical history, drug and allergy history, family history, social history, contraceptive history, sexual history, laboratory tests, differential diagnosis, suspected diagnosis, final diagnosis, management, physical examination including general appearance, vital signs, BMI, and general examination of head, eyes, ears, nose, throat and neck. The goal is to obtain a comprehensive history and perform an examination of the patient to reach an accurate diagnosis and develop an appropriate management plan.

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    15 views6 pages

    Clinical Approach To The Patient: Always Listen To The PT They Might Be Telling You The Diagnosis

    Uploaded by

    wardo adam
    This document outlines the components of an obstetrics and gynecology case history and physical examination. It includes sections to document personal data, present complaint, present illness, obstetric history, menstrual history, medical history, surgical history, drug and allergy history, family history, social history, contraceptive history, sexual history, laboratory tests, differential diagnosis, suspected diagnosis, final diagnosis, management, physical examination including general appearance, vital signs, BMI, and general examination of head, eyes, ears, nose, throat and neck. The goal is to obtain a comprehensive history and perform an examination of the patient to reach an accurate diagnosis and develop an appropriate management plan.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 6

    Banadir Hospital HISTORY TAKING & PHYSICAL EXAMINATION

    OBsGyn Department

    Clinical Approach to the patient


    OBSGYN CASE HISTORY AND PHYSICAL EXAMINATION

    “Always listen to the pt they might be telling you the


    diagnosis”
    1. Personal data(as NASEOMADR)
    Name: , IPNO:
    Age: , DOA: / / , Residence Region:
    Occupation: , Education: ,
    Gravida: , Parity: , Gestation age: weeks.
    2. Present complaint
    --------------------------------------------------------------------------------------------
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    3. Present illness( ask OPQRSTA or SOCRATES)
    --------------------------------------------------------------------------------------------
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    4. 0bstetric history
    A. Current pregnancy
    ----------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------------
    B. Previous pregnancies
    ----------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------------

    Page 1
    Banadir Hospital HISTORY TAKING & PHYSICAL EXAMINATION
    OBsGyn Department

    ----------------------------------------------------------------------------------------
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    5. Menstrual history
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    6. Medical history
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    7. Surgical history
    --------------------------------------------------------------------------------------------
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    8. Drug and allergic history
    a. Current:
    --------------------------------------------------------------------------------------------
    --------------------------------------------------------------------------------------------
    b. Past:
    -------------------------------------------------------------------------------------------
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    9. Family history
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    --------------------------------------------------------------------------------------------
    10. Social history
    --------------------------------------------------------------------------------------------
    --------------------------------------------------------------------------------------------
    --------------------------------------------------------------------------------------------
    11. Contraceptive history

    Page 2
    Banadir Hospital HISTORY TAKING & PHYSICAL EXAMINATION
    OBsGyn Department

    --------------------------------------------------------------------------------------------
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    12. Sexual history


    --------------------------------------------------------------------------------------------
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    13. Laboratory tests
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    14. Differential diagnosis
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    15. Suspected Diagnosis
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    16. Final Diagnosis
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    17. Management
    --------------------------------------------------------------------------------------------
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    --------------------------------------------------------------------------------------------
    --------------------------------------------------------------------------------------------
    --------------------------------------------------------------------------------------------

    Page 3
    Banadir Hospital HISTORY TAKING & PHYSICAL EXAMINATION
    OBsGyn Department

    --------------------------------------------------------------------------------------------
    --------------------------------------------------------------------------------------------
    --------------------------------------------------------------------------------------------

    PHYSICAL EXAMINATION
    1. General appearance
    ----------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------------
    2. Vital signs
    ----------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------------
    3. BMI( W/H2)
    ----------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------------
    4. General examination
    A. HEENT
    -------------------------------------------------------------------------------------
    -------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------
    B. Neck
    -------------------------------------------------------------------------------------
    -------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------
    C. Breast
    -------------------------------------------------------------------------------------
    -------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------
    D. Heart and lung
    -------------------------------------------------------------------------------------
    -------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------
    E. Abdomen
    Page 4
    Banadir Hospital HISTORY TAKING & PHYSICAL EXAMINATION
    OBsGyn Department

    - Inspection:
    ---------------------------------------------------------------------------------
    ---------------------------------------------------------------------------------
    --------------------------------------------------------------------------------
    - Palpation:
    ---------------------------------------------------------------------------------
    ---------------------------------------------------------------------------------
    --------------------------------------------------------------------------------
    - Auscultation:
    ---------------------------------------------------------------------------------
    ---------------------------------------------------------------------------------
    ---------------------------------------------------------------------------------
    F. Back
    -------------------------------------------------------------------------------------
    -------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------
    G. Extremities
    -------------------------------------------------------------------------------------
    -------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------
    5. Pelvic examination
    A. Vulva
    -------------------------------------------------------------------------------------
    -------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------
    B. Speculum
    -------------------------------------------------------------------------------------
    -------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------
    C. Bimanual examination
    -------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------
    -------------------------------------------------------------------------------------
    6. Rectal examination

    Page 5
    Banadir Hospital HISTORY TAKING & PHYSICAL EXAMINATION
    OBsGyn Department

    ----------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------------
    ----------------------------------------------------------------------------------------

    Summary review
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    Page 6

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