OB-GYNE HISTORY Date of assessment: Time of assessment: General data Name: Age: Sex: Birthdate: Birthplace: Chief Complaint

Informant: Reliability:

Occupation: Marital Status: Religion: Race: Address:

How many times admitted in present hospital? Date of admission: Time of admission:

History of Present Illness Chronological sequence of events leading to CC/admission

Location: Quality: Severity/Quantity: Timing: Setting: Exacerbating factors: Relieving factors: Associated manifestation: Trauma: Nature OI Place OI Date OI Time OI Allergies Medications Past illnesses Last meal Events preceding Immunizations BCG DPT MMR OPV Hep B (3 doses) HPV (women) Flu (every year) Pneumococcal (every 5 years) Others Medications Name of drug Dosage

Response to illness Effect of illness on life

Past Medical History Childhood diseases Chicken pox (bulutong) Measles (tigdas) German measles Mumps (beke) Primary complex (pinainom ng bitamina para sa baga) Asthma (hika)

Diagnosed adult illnesses What When diagnosed

Monitoring (usual, highest readings)

Maintenance

Frequency

Route

Indication

Hospitalizations Where

When

Why

How long confined

Surgeries Where

When

Why

How long confined

Complications

Accidents and injuries NOI POI DOI TOI Family History Health and ages of parents, siblings, children, or ages at death and causes Relative Age Illness

Health maintenance practices Screening tests Allergies

Illness in the family similar to the patients illness Personal Social History Work environment Income Educational attainment Diet Exercise Smoking Alcohol Illicit drug use Home environment Household members OB-GYN History G_P_ (_ _ _ _) No. of pregnancy

Cancer Heart dse TB Diabetes Hypertension Anemia Hemophilia Thalassemia Rheumatic fever Mental illness Water supply Drinking water Waste disposal Toilet Community diseases Family Social groups Personal interests Coping style

LMP Year Delivery

PNMP Place

Attendant

Gender of baby

AOG

Birthweight

Complications

Present pregnancy AOG

EDD

Menstrual History Menarche Interval Duration Amount Dysmenorrhea Bleeding between periods Pre-menstrual tension Age at menopause Menopausal symptoms Post-menopausal bleeding Prenatal History Trimester No. of check ups

Sexual History Coitarche No. of partners Birth-control methods Sexual preference Interest Function Satisfaction Any problems Dyspareunia Concerns about HIV infection

Place

Diagnostics & results

Medications with dose & frequency

Complications

Review of Systems General Usual weight Weight change Clothes that fit more tightly or loosely than before Weakness (panghihina) Fatigue (madaling mapagod) Fever (lagnat) Skin Rashes Lumps Sores Itching Dryness Changes in color Changes in hair or nails Changes in size or color of moles Head, Eyes, Ears, Nose, Throat Head Head ache Head injury Dizziness Lightheadedness Eyes Vision Eyeglasses Last examination Pain Redness Excessive tearing Double vision Blurred vision Spots Specks Flashing lights Glaucoma Cataract Ears Hearing Tinnitus Vertigo Earaches Infection Discharge Nose Frequent colds Nasal stuffiness Discharge Itching Nosebleeds Throat Condition of teeth & gums Bleeding gums Dentures Last dental examination Sore tongue Dry mouth Frequent sore throats Hoarseness

Neck Swollen glands Goiter Lumps Pain Stiffness in the neck Breasts Lumps Pain Nipple discharge Self examination Respiratory Cough Sputum (color, quantity) Hemoptysis Dyspnea Wheezing Pleurisy Last chest x-ray Asthma Bronchitis Emphysema Pneumonia TB Cardiovascular Heart trouble High BP Rheumatic fever Heart murmurs Chest pain or discomfort Palpitations Dyspnea Orthopnea Paroxysmal nocturnal dyspnea Edema Past ECG Gastrointestinal Trouble swallowing Heartburn Appetite Nausea Bowel movements Stool color and size Change in bowel habits Pain with defecation Rectal bleeding Black or tarry stools Hemorrhoids Constipation Diarrhea Abdominal pain Food intolerance Excessive belching or passing of gas Jaundice Liver, or gallbladder trouble Hepatitis

Urinary Frequency of urination Polyuria Nocturia Urgency Burning or pain during urination Hematuria Urinary infections Kidney or ank pain Kidney stones Ureteral colic Suprapubic pain Incontinence Hesitancy Dribbling Genital Vaginal discharge Itching Sores Lumps STDs and treatments Exposure to DES Peripheral Vascular Intermittent claudication Leg cramps Varicose veins Past clots in the veins Swelling in calves, legs, or feet Color change in ngertips or toes during cold weather Swelling with redness or tenderness Musculoskeletal Muscle or joint pain Stiffness Arthritis Gout Backache Location of affected joints or muscles Swelling Redness Pain Tenderness Stiffness Weakness Limitation of motion or activity Timing Duration Trauma Neck or low back pain Joint pain with systemic features Fever Chills Rash Anorexia Weight loss Weakness

Psychiatric Nervousness Tension Mood Depression Memory change Suicide attempts Neurologic Changes in mood, attention, or speech Changes in orientation, memory, insight, or judgment Headache Dizziness Vertigo Fainting Blackouts Seizures Weakness Paralysis Numbness or loss of sensation Tingling or pins and needles Tremors or other involuntary movements Seizures Hematologic Anemia Easy bruising or bleeding Past transfusions Transfusion reactions Endocrine Thyroid trouble Heat or cold intolerance Excessive sweating Excessive thirst or hunger, polyuria Change in glove or shoe size

Any other things that we havent talked about that youd like to mention? Any other questions you want to ask?

OB-GYNE PHYSICAL EXAMINATION Vital Signs T__C oral axillary rectal PR _____ beats/ min regular irregular HR _____ beats/ min regular irregular RR _____ breathes/ min regular irregular BP __________ sitting standing Height ___cm Weight ___kg General Survey LOC: Conscious Drowsy Stuporous Comatose Others: ______________________ Coherence: coherent incoherent Orientation: oriented disoriented to: Time/ Place/ Person General appearance: Signs of distress Cardiorespiratory Pain Anxiety Development: endomorph mesomorph ectomorph well fairly poorly looks according to age looks younger/older Nutrition: well nourished obese cachexic Emotional state: calm worried restless tense Others: ________________________ Gait: coordinated uncoordinated staggering Shuffling stumbling unable to walk alone walks with assistive devices Skin General color: Pallor Jaundice Flushed Cyanotic Texture: Smooth Rough others: _________________ Turgor: Good Fair Poor Temperature: Warm Cool others: ________________ Moisture: Dry Wet/clammy oily Others: Petecchiae Ecchymosis Lesions/ rashes: ________________________ Edema : Pitting Non-pitting (Grading: ___) Pedal L R Head Configuration: Normocephalic Others:_________________ Masses ______________________________ Fontanelles: Closed Open: ______________________ Sunken Bulging Hair: Fine Coarse Dry Normal distribution Alopecia Scalp: Clean Dandruff Lice Lesions Others: _____________________ Ears External Pinnae: Normoset Symmetrical Tenderness Gross abnormalities: ______________________ External canal: Impacted cerumen Discharge: Foul smelling Serous Purulent Mucoid Gross hearing: Symmetrical Deafness R L Eyes Lids: Symmetrical Edema/Swelling R L Ptosis RL Periorbital region: edema sunken discoloration Conjunctiva: pinkish pale lesion discharge Sclera: Anicteric Subicteric Icteric Hemorrhages Cornea & Lens: smooth clear lesions opacity Arcus senilis Pupil size: equal unequal R= ___mm L= ___mm Reaction to light: R brisk sluggish fixed L brisk sluggish fixed Reaction to accommodation: uniform unequal Convergence: uniform unequal Visual acuity: Grossly normal Wears eyeglasses/ contact lenses Nose Nasolabial Fold: Symmetrical Shallow R L Septum: Midline Deviated Perforated Mucosa: Pinkish Pale Reddish Discharge: Serous Purulent Mucoid Bloody Patency: both patent obstructed R L Masses/ Lesions: ________________________ Gross smell: Symmetrical Olfactory deficiency R L Sinuses: Tender Non-tender Mouth Lips: Pallor Cyanosis Dryness/ Cracks Lesions Tongue: Midline Deviated R L Atrophy Fasciculation Lesions Teeth: Complete Missing __ Caries Dentures Braces/ Retainers Gums: Pinkish Pale Bleeding Tenderness Mucosa: Pinkish Pale Cyanotic Speech: Intact Sturred Aphasic Others: ___________________________ Pharynx Uvula: Midline Deviated R L Mucosa: Pinkish Pale Reddish Tonsils: Not inflamed Inflamed Neck Trachea: Midline Deviated R L Lymph nodes: Nonpalpable Palpable/enlarged Tender Thyroids: Nonpalpable Enlarged Others: Normal ROM Neck rigidity NVE at __ angle R L Masses Chest and Lungs Inspiration- Expiration ratio: ___:___ Breathing Pattern: Effortless Hyperpnea Tachypnea Dyst use of accessory muscles Others: __________ Shape of chest: APL ratio: ___(AP) :___ (L) Barrel Funnel Pigeon Others: _____________________________ Chest expansion: Symmetrical Decrease/ Lag R L Tactile Fremitus: Symmetrical Dec/ Inc at __________ R L Pecussion: Resonant Dullness at __________ R L Hyperresonant at __________ R L Breath sounds: Vesicular Bronchovesicular at __________ Bronchial at ____________ Abnormal breath sounds: Wheezes _____ R L Rales _____ R L Friction rub _____ R L Rhonchi _____ R L Heart Pericordal area: Flat Bulging Adynamic Dynamic Tenderness Heave Thrill PMI at __________________ Apical beat: ________ beats/min Heart sounds: Distinct Faint S1 __S2 @ base S1 __S2 @ apex Extra sounds S3 S4 Murmur, grade __ best heard at_______ Breast and axillae Size and symmetry: Equal Unequal Contour: Masses ___________ R L Dimpling __________ R L Skin: Redness Edema Tenderness: Tender Non-tender Nipple and Areola: Inversion Flattening or retraction Edema Deviation to R L Edema Abdomen Skin: Dilated veins Striae Scars Rashes Lesions at _____________________________________________ Umbilicus: Sunken Bulging Hernia Configuration: Flat Globular Protuberant Scaphold Symmetrical Asymmetrical Masses at: _____________________________ Bowel sounds: Normoactive Hyperactive Hypoactive Absent Rate: _______/min Bruit: Absent Present at __________ Pecussion: Tympannic Hypertympannic Fluid wave Shifting dullness Palpation: Muscle guarding direct tenderness Rebound tenderness For Pregnant women: Fundic Height: ___cm LM1 LM2 LM3 LM4 FHT ____beats/min Genito-urinary System Labia: Symmetrical Asymmetrical Lesions at _______________ Pinkish Discoloration Edema Vaginal orifice: Discharge : Purulent Bloody foul smelling Others: Swelling Lumps or nodules at __________________ Speculum Exam Cervix Vagina Discharge Bleeding IE Cervix Uterus Adnexae Back and Extremities Peripheral pulses: symmetrical regular warm absent faint Weak Strong Bounding Nail: pink pale cyanosis inflammation clubbing delayed cap refill Joints: redness warmth crepitation Swelling at _______________________ Tenderness at _______________________ Full ROM Decreased ROM at _______________________ Muscle: size equal atrophy at ________________________ Normal tone Hypertonic Flaccid Fasciculation Tics Tremors Strength equal Weakness at ________________________________ Paralysis at ________________________________ Spine: midline Scoliosis at __-__ Kyphosis at __-__ Lordosis at __-__ Kidney: CVA Tenderness

IMPRESSION G_P_ (_ _ _ _) Complications

Pregnancy uterine, ________ wks AOG

Fetal presentation _______________

In labor/Not in labor