OB-GYN PATIENT HISTORY AND PHYSICAL EXAMINATION

Name: Age: Case #:

Address: Civil Status: Religion:

DOB: DOA:

OB Score: G__P__ (_____) LMP: AOG: EDC:

Chief Complaint: Informant:

History of Present Illness Danger SIgns

● When cognizant of pregnancy and how ▢ Nausea/Vomiting ▢ Contractions

▢ Headache/Dizziness ▢ Decreased Fetal Movement
● Early signs of pregnancy (breast tenderness, amenorrhea, ▢ Visual Disturbances ▢ Watery vaginal discharge
fatigue, nausea, vomiting) ▢ Edema ▢ Vaginal bleeding
▢ Fever ▢ Dysuria

● Number of PNCUs (Where, When, By whom) Risk Factors

● Medication/s ▢ Teenage pregnancy (<19yo) ▢ Other medical conditions

▢ Elderly pregnancy (>35yo) ▢ Heart diseases
▢ Poor obstetric history ▢ Pulmonary diseases
▢ Consecutive abortions ▢ Hypertension
● Immunization/s
▢ Hx of preterm delivery ▢ Diabetes mellitus
▢ IUPD ▢ Renal diseases
● Work-up/s and result/s ▢ Anemia
▢ Congenital anomaly
▢ Malnutrition
▢ Infections (PTB, STI, UTI)
▢ Immunologic diseases
▢ Malignancies: ▢ Neurologic disorders
_____________________ ▢ GIT disorders
▢ Psychiatric Disorders
_____________________
● Abnormal finding/s

OB-GYN History

Menstrual Menarche was at __ years old with ▢ regular / ▢ irregular intervals of ____ days, lasting ____ days per cycle
using about ____ lightly / moderately / severely soaked pads per day. Noted ▢ dysmenorrhea, ▢ headache,
▢ nausea, ▢ vomiting and ▢ fever. Intensity: _______, Day: ________ LMP: ________ PMP: ________.

Obstetric The patient is a G__P__ (_,_,_,_). Patient is currently at ____weeks __/7 days AOG by ▢ early UTZ / ▢ LMP, ▢
cephalic / ▢ breech in labor. ___ Prenatal check-ups were done at ____________.
Maternal conditions: Medications/interventions done:

Gynecologic ▢ abnormal vaginal discharge ▢ abnormal vaginal bleeding ▢ vaginal pruritus

▢ STI/STD/HIV ▢ UTI, medications: _____________ ▢ Past gynecologic surgery: _____________
▢ Pap smear, date:_______________ results:_______________

Sexual Coitarche was at the age of ____, with ___ sexual partner/s, ▢ Dyspareunia ▢ Post-coital bleeding.

Contraceptives ▢ Withdrawal method ▢ Condoms ▢ OCPs ▢ IUDs ▢ implants ▢ Others: ___________________

Dose and duration: __________________________ Reason for discontinuation: ________________________

Immunization COVID-19 vaccine: ____________ (1st dose: _______; 2nd dose: _______) Booster: _______
▢ Completed childhood vaxx; ▢ HPV; ▢ Flu; ▢ Hep B; ▢ Tdap; ▢ Varicella, Others: _________________
Obstetric Hx: G___P___ (Term ___ Preterm ___ Abortion ___ Living ___) EDD (-3,+7,+1): :

Date of delivery Preterm/Term/Post term Route of delivery Place of delivery Fetomat Complications
G1
G2
G3
G4
G5
G6
G7

Past Medical History

Childhood diseases: Comorbidities: Surgeries: Medications:

▢ Measles ▢ Hypertension
▢ Mumps ▢ Diabetes mellitus
Hospitalizations:
▢ Rubella ▢ Bronchial Asthma Vitamins:
▢ Chickenpox ▢ Thyroid disease
▢ Heart disease Trauma/Accident
▢ Lung disease Blood type:

Allergies Social/Environmental History Family History

▢ None known Occupation (if employed): __________________ HTN Diabetes Mellitus PTB
▢ Food: ____________________ The ____________ is the main provider of the Asthma Thyroid disease Cancer
▢ Drugs: ___________________ family with highest educational attainment and Arthritis Cardiac disease Renal
Others: _____________________ occupation of _____________. Others:
Current diet consists of ____________________.
Personal/Social History Electricity is supplied by ____, water is supplied
by______, drinking water is sourced from _____, Symptoms similar to patient:
▢ Smoker: ___ pack years,
and garbage is collected ______.
___ sticks per day
Pets kept in the household:
▢ Alcoholic beverage drinker
▢ Coffee drinker
▢ Illicit drug user: _____________

Review of Systems

GEN Fever Chills Weight loss/gain Fatigue Sweating RESPI Dyspnea Cough Tachypnea Hemoptysis Wheezing

SKIN Rash Pigmentations Hair loss Pruritus Pallor GIT Abdominal pain Diarrhea Nausea/ Vomiting Constipation
Encopresis Passage of worms Jaundice Appetite loss

HEAD Change in Head Size Scars/lesions GUT Dysuria Urgency Hematuria Oliguria Retention
Hesitancy Change in color Stream

EYES Blurring of vision Lacrimation Itchiness Pain REPRO Menses: Regular / Irregular Abnormal vaginal bleeding
Redness Dysmenorrhea Post-coital bleeding Menopause ______

EARS Hearing loss Discharge Tinnitus Pain MS Muscle pain Joint pain Limited ROM Limping

NOSE Congestion Discharge Epistaxis Frequent NEURO Headache Dizziness Seizure Tremors Sleep problems
colds/cough Weakness/paralysis Memory loss Memory deterioration

THROAT Sore throat Salivation Toothache Dysphagia HEMA Bruising Bleeding Hematemesis Hematochezia

CVS Chest pain Palpitations Cyanosis Orthopnea ENDO Polyuria Polydipsia Polyphagia Palpitations
Easy fatigability Fainting Spells Cold/Heat Intolerance Thyroid problems
 Physical Examination

Vital Signs HR: BP: RR: Temp: O2Sat: .

Present Weight: Pre-pregnancy weight: ___________ Height: BMI: .

Gen Survey Awake alert ambulatory conversant acutely/chronically ill in pain in cardiorespiratory distress
Others:

Skin No pallor, jaundice, cyanosis, rash, lesions, smooth, warm to touch

HEENT H: normocephalic, symmetrical facial features, no palpable mass, hair with normal texture and equally distributed
E: anicteric sclerae, pale palpebral conjunctivae, not sunken
E: no gross deformities, no ear discharge, no masses or tenderness
N: symmetrical nose, midline septum, no alar flaring, no nasal discharge
T: no lesions, masses, tonsillo-pharyngeal congestion, no cervical lymphadenopathies

Chest/Lungs No chest wall deformities, equal chest expansion, no retractions, symmetrical tactile fremitus, (-) palpable crepitus,
clear and resonant breath sounds on all lung fields

Breast No dimpling, retraction, masses, discharge

Heart Adynamic precordium, normal rate & regular rhythm / tachycardic, distinct S1&S2, no thrills, heaves, murmurs

Abdomen Soft, flabby, and symmetric abdomen, normoactive bowel sounds, good skin turgor, (-) organomegaly
Scars: ____________________________ FH: ______ FHT: _______ Leopold’s LM1: ▢ breech
LM2: fetal back on maternal ▢ left ▢ right LM3: ▢ cephalic ▢ ballotable / ▢ non-ballotable LM4: ▢ unengaged

Pelvic No masses, lesions, discharge, normal-looking external genitalia

Speculum exam: vaginal canal pink and smooth, cervix, pink/violaceous, smooth, no excoriations, no bleeding
Internal exam: cervix is smooth, firm, closed/admits tip, posterior (include dilatation, effacement, and station, when
applicable), uterus enlarged to ___ week size; Bishop score: 1; Pelvimetry: adequate
RVE (if needed): Good sphincter tone, smooth rectal mucosa, no palpable masses/nodularities, no pararectal
tenderness

Spine Midline, no gross deformities

Rectum & Empty rectal vault, no masses palpated, non-prolapsed, (-) blood, (-) stool on examining finger
Genitalia Grossly male / female, Inguinal region not assessed

Extremities Full and equal / decreased distal pulses, warm / cold to the touch, CRT <2s / >2s, ( ) edema

Neuro Exam F - Awake, alert, fluent speech, good concentration CN VII - no facial asymmetry, able to raise eyebrows, smile, puff
P - No apraxia, finger agnosia, acalculia, agraphia, R-L out cheeks
disorientation CN VIII - intact gross hearing
T - Oriented to time, place, and person; good immediate CN IX, X - able to swallow
memory able to recall 3/3 items, Intact recent and remote CN XI -can do head turning and shoulder shrug with resistance
memory CN XII - tongue midline
O - Can identify objects, person and colors Motor - 5/5 on all extremities. 5/10 pain on lower extremities
upon testing ROM and strength
CN I - not assessed Sensory - 100% on all extremities (light touch and pain)
CN II, III - pupils 3-4mm EBRTL; (+) direct and consensual Cerebellar - no nystagmus, no dysdiadochokinesia, no
reflex dysmetria
CN III, IV, and VI - intact EOMs DTRs - 2+ on all extremities
CN V - 100% V1-V3, good temporalis & masseter tone

ADMITTING DIAGNOSIS
OB score, pregnancy uterine, AOG by LMP/1st trimester ultrasound, cephalic not in labor, LTCS, problems
Diagnostics:
● CBC/PC
● BTRh
● HbsAg
● HIV
● RPR
● TVS
● 75g OGTT
● Pelvic UTZ
● BPS
● RT-PCR
Medications:
● FeSO4 1 tab OD
● CaCO3 1 tab OD
● OB MVT 1 tab OD
Plan:
● Diet as tolerated (DAT)
● Increase oral fluid intake (OFI)
● Milk BID
● Daily body and perineal hygiene
● Daily fetal kick count
○ (multigravid: 16 weeks, nulli: 20 weeks; 10
movements in 2 hrs, if none observe for 4 more hours
if none, check-up!)
● Watch out for 10 danger signs of pregnancy,
Work-up/s and result/s:
● 1st trimester CBC
● 3rd trimester CBC
● ABO Rh blood typing
● Urinalysis
● FBS (<24 weeks)
● 75g OGTT (24-28 weeks)
● HbsAg
● VDRL
● HIV
● Pap smear
● 1st trimester ultrasound
● 2nd trimester ultrasound/congenital anomaly scan
● 3rd trimester ultrasound
● COVID-19 RT-PCR