Done by;Taher Al-Mekhlafy,Group D,Batch 19, Division of Medicine,Taiz

University

Obstetric sheet
(1)Personal history;
Female patient Madam……………………………………………………………,………………years old, married
or…………… for …………………..years, gravida………., parity……….,……..abortion, she was burn
in ……………………………. and living at…………………………………,her blood group is …………..,
housewife or ……… …………… ,( with or without) special habit of medical important
[……………/day].

Her husband Mester…………………………………………………..., …………………..years old ,his

job……………………., blood group is………..,with chewing qat or without any special habit
of medical important,…………..consanguinity.

The date of admission on…………….on ……./……../……, at……… P.M/A.M

History taking from patient herself or from………………………… ,.on……………………on..

…./…./…….. at……………….A.M/PM

(2)Chief complain;
She was pregnant at her ………….. month, complaining of
………………………………………..for………………..duration before admission.

(3)History of present illness; [yes or no]

She was pregnant (primigravida OR multigravida )at ……….weeks as evident by U/S
OR by the frist day of regular LMP which was on ……/…../……. So her EDD is going
to be on ……../………/……….. .

Her pregnancy planning [………….]non planning [……………….],discover by delayed

her menses[………….], nousea&vomiting[………..] and confirm by urine strip test
[……….] at home and U/S [………….] .
(A)In the first trimester;

She passed through her first trimester (smoothly if no complication as

VB,discharge) with nausea [………] ,vomiting[……..]……..times per day, [yes/no]
related to food, [yes/no] excessive,[……….] dizziness,[………]frequency of urination,
[………….] headache, [……….] fatigue, , [………..] antenatal care(regular/irregular].if
had ANC give time …………..week and told her pregnancy was (normal/abnormal)
and given…………………

history of [………….]vaginal bleeding, [……] discharge,[………..]LAP

-If present VB or discharge OR LAP you give the time and the investigation,
treatment.

Patient had history of Vaginal bleeding Patient had history of Vaginal discharge
at ……….week [ yes/no]associated with at……..week [ yes/no]associated with
LAP[……], [………..] discharge VB[……], [………..] LAP

-She attended ANC and investigated She attended to ANC and investigate by
by………………. …………………….and she ………………. And she told that she had
told that she had……………………….And ………..and treated
treated by…………… by…………………………………..

Patient had history of LAP at ……….week [ yes/no]associated with VB[……], [………..]

discharge
-She attended ANC and investigated by………………. …………………….and she told that
she had……………………….And treated by……………

(B)In second trimester;

She was perceived the fetal movement at ………………….,………………per day.

Nausea, vomiting,frequency of urination, dizziness (improved/non improved)

(yes/no)patient attended for (regular/irregular)ANC ………. Times during her
second trimester and she told that she had (normal/abnormal) pregnancy and
given ………………..

history of ;[……….] persistent headache, blurring of vision [………..],excessive

vomiting[………], epigastric pain [………], diminished fetal movement[…….],vaginal
bleeding[…….],gush of fluid[………],lower limb edema[……].

-If present VB or discharge you give the time and the investigation, treatment.

Patient had history of ………………………… Patient had history of ………………………………..

at ……….week [ yes/no]associated with
LAP[……], [………..] discharge
-She
attended………………………………………………
……………………………………………………………
…………..and investigated by……………….
and she told that she
had………………………………………………………
………..And treated
by…………………………………………………………
…………………..
at……..week,(yes/no)associated
with[…….]pain,[……..]VB.
She attended to ANC and investigate by
………………. …………………………………….And she
told that she had
…………………………………………………………………
………………………...and treated
by………………………………………………………………
…………………………………………………………………
…………………………………………..

(C)in the third trimester;

[increase/decrease] frequency of urination,[yes/no] difficulty of walking

history of ; persistent headache[………..],blurring of vision […………], excessive

vomiting[……..],epigastric pain[……………],diminished fetal movement […………….],
vaginal bleeding [……….],gush of fluid[………],LLE[……….].

-(yes/no) she attended to ANC at her………….month, and did ……………………..which

show[normal/abnormal] pregnancy with ………………..position.

IF ooccured one of these warning symptom was present analysis it as the

following;
Patient had history of Vaginal bleeding at ……….month , [ yes/no]associated with
with persistent headache[………..],blurring of vision […………], excessive
vomiting[……..],epigastric pain[……………],diminished fetal movement […………….], or
bleeding from other orifices,

-She attended ANC and investigated by………………. and she told that she
had…………………………..And treated by……………………………………………………………………..

Patient had history of LOWER LIMBE Patient had history of Blurring of

EDEMA; started at…….month,She
attended to
……………………………………….. and
investigate by ………………. And she told
that she had
…………………………………………………………
…………………………………………………………
…………………………and
treatedby…………………………………………
…………………………………………………………
…………………………………………………………
…………………..
vision;at………………month,She attended
to……………………….
……………………………………….. and
investigate by ………………. And she told
that she had
………………………………………………………………
………………………………………………………………
………..and treated
by……………………………………………………………
………………………………………………………………
………………………………………..

Patient had history of Gush of fluid; Patient had history of persistent

started at………….month
She attended to ANC and investigated
by
…………………………………………………………
……………………………. And she told that
she had
…………………………………………………………
………………………………………………………….
and treated
by………………………………………………………
……………………….
……………………………………………………..
headache; at………………month,
She attended to……………………….
……………………………………….. and
investigate by ………………. And she told
that she had …………………………………………..
………………………………………………………….and
treated
by……………………………………………………………
………………………………………………………………
…….
Patient had history of Epigastric pain
;started at…………………..month,
She attended to……………………….
……………………………………….. and
investigated by ………………. And she
told that she had
…………………………………………………………
…………………………………………………………
…………………..and treated
by………………………………………………………
………………
(D) Analysis of Chief complain;
-she was well till…………………hourse/days before admission ,she started to
complain of………………………………………….
Vaginal bleeding at ……….week which
was (sudden/acute/gradual),
(progressive/regressive/intermittent)co
urse,for…………………,(with/without)
blood
clot,(spotting/average/excessive)in
amount,(fresh bright red/ dark red) in
color, she used ……………pads, [
yes/no]associated with LAP[……],
[………..] discharge
and………………………………………………………
…………………………………………………………….
-She attended to
……………………………………………………………
……………………………………………………………
……………. and investigated
by…………………………………………………………
……………………………………………………………
……………………………………………………………
…….. and she told that she
Patient had history of Excessive
vomiting;)at…………………..month,
She attended to……………………….
……………………………………….. and
investigated by ………………. And she told
that she
had…………………………………………………………
………………………
………………………………………………………………
………..and treated
by……………………………………………………………
…………………………………………………………….
Vaginal discharge
at……..week,for………………….,(odorless/offe
nsive),(spotting/average/excessive)in
amount,(watery/viscid)in consistency,
(colorless/………………in
color),(yes/no)associated with[…….]pain,
[……..]VB
and……………………………………………………………
………………………………………………………………….
She attended to
…………………………………………………………………
…………………………………………………………. and
investigated by ………………. And she told
that she had
…………………………………………………………………
…………………………………………………………………
……………...and treated
by…………………………………..
had………..And treated by……………

Lower abdominal pain started (sudden/acute/gradual)at…………………..month,

progressive/regressive/intermittent)in course ,for…………………………………………….,
(yes/not)radiate to……………………………………..,
(Colicky/Heaviness/Burning/Stitching/Stabbing/Throbbing/ dull aching)
,increase by………………………………….. ,decrease by…………………………………………
(associated/no associated) with [……………………………………………………………..]
discharge, Vaginal bleeding[…………………………………………………………………..]
So She attended to
…………………………………………………………………………………………………………………………….
and investigated by ………………. And she told that she had ………..and treated
by…………………………………..

c/s done in……………..A.M/P.M ,[………..]under spinal anesthea ,lasting

for……………..hours,[with/without] transfer of ……….unit of blood…………………
[yes/no] history of intraoperative[……….]or postoperative complicatiom which is
…………………………………………………………………………………………………………………………….

(E) Outcome ; is [single/multiple],[alive/death],[male/female] ,baby with average

weight………………….. and the patient now in………………… day postoperative.

(F)Review of Other Systems:

General Symptoms:. Fever. Loss of Weight. Night Sweating. Loss of Appetite.

Cardiovascular System:. Chest Pain. Cyanosis. Palpitation. Edema.

Respiratory System:. Dyspnea. Cough. Sputum. Hemoptysis. Wheezing.

Gastrointestinal Tract:. Dysphagia

. Epigastric Pain. Diarrhea. Constipation. Rectal Bleeding.

Renal System:. Dysuria. Frequency. Urgency

-Central Nervous System:. Headache. Blurring of Vision. Syncope. Convulsions.

Tinnitus. Vertigo. Dizziness. Loss of Memory. Muscle Weakness. Paralysis.

Musculoskeletal System:. Joint Pain. Bone Pain. Weakness. Stiffness. Paralysis..

Other: ………………………………………………...

Endocrine System:. Polydipsia. Polyuria. Polyphagia. Heat Intolerance. Cold

Intolerance. Other: …………………………

Hematological System:. Easy Fatigability( ). Melena( ). Skin Rash( ).

Petechiae( ). Ecchymosis .( ).Epistaxis. Other: ………………..

(4) menstrual history;

She was menarche at…………….age,[regular/irregular]cycle, with
[scanty/average/excesive] for………..days, per ……………days, number of pads/day (
) ,[with/ without] Intermenstrual Pain,[with/without] spotting Intermenstrual
Bleeding,[with/without] Dysmenorrhea (SPASMOTIC‫اثناء الدوره‬-CONGESTED ‫قبل‬
‫)الدوره‬

(5)Obstetric history; Obstetric code ;FPAL

Full term delivery Pre-term delivery Abortion Living children
)more 37week) 37-28 >=28

Year Duration any Mode of Place of Male or Lactation

of of disorder termination termination female and
preg pregnan complication
cy

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3

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(6)contraceptive history;
Method……………………………,started
……………………………………………….for……………………..duration ,if stoped give[when
and why]
………………………………………………………………………………………………………………………………
…………and .

Or no history of family planning(……………)

(7)Gynecology history;
[yes/no]history of;

1-breast discharge(……).2-uterine disease or tumor(…..)

3-ovarian cyste(……).4-PID(…..).5- STD(…..).6pap smear(………….)

(8)Past history;
[yes/no]Past medical history of;smilar attacks ,HTN(…..),D.M(…..),previous
surgery[……]hospitalization[……..],blood
transfusion[………….],trauma[………],STD[…….],[no/yes]allergy to ……………..food
and drug

-If present give [duration and treatment]………………………………………………………………………………………………………………

----surgery[duration]…………………………………………………………………………………………………………………………………………
Chronic disease asHTN,D.M IF present you must make them in the starting of
speaking about chief complain(patient with HTN before pregnancy diagnosed by
……………doctor and treated by……………………………..

Family history;
[……………]Similar condition in her family,[…………………]history of chronic
disease(HTN/D.M,heart disease,tumer],[……….]history of twins ,[…….]congenital
anomalies ,sudden death[………]and[……………]consanguinity between
wife/husband.

Socio-economic history;
Patient lives ………………………………consist of………………….rooms,[bad/good]water
supply,[bad/well] ventilation,[well/bad]nutrition,[with/without]electericity and
[with/without] animal contact.

Provisional Diagnosis;
Quadruple Name: ………………………………………………………………………,…………………….
………years old

She is Para: ………………………… with ………………………..complication

Its Outcomes: is [single/multiple],[alive/death],[male/female] ,baby wand the

patient now in………………… day postoperative in [female department/obstetric
department] for observation and follow up.