Obstetrics CASE PROFORMA PHYSICAL EXAMINATION

Name, Wife of, Age, Booked/Not Booked, Address, Education, -Mental state and intelligence (CCC)
Occupation, Income, Marital Status, Years of Marriage, -Build, state of nutrition
Literacy Status, Religion, Socioeconomic Status -Decubitus and Attitude, Any facies
HISTORY Check Thyroid enlargement, Breast, spine and gait.
[A __ year old patient, supine decubitus who is __ built __
Chief Complaints: nourished is conscious, coherent, cooperative, and
-This lady was admitted for safe institutional delivery in view of comfortably seated/lying on the bed, well oriented to time,
previous CS (For Previous LSCS Case) place and person]
-Difficulty in breathing, palpitations, chest pain etc since (for heart There is No Pallor, Icterus, cyanosis, koilonychias,
disease complicating pregnancy) generalised lymphadenopathy and no pedal edema.
-This lady was admitted for safe institutional delivery in view of VITALS: Temperature: Pulse, RR, BP.
Increased Blood pressure (for PIH case)
-This lady was admitted for safe institutional delivery in view of LOCAL EXAMINATION-ABDOMEN
Twin pregnancy
After taking informed consent, patient is in supine position
-Breathless, palpitations, weakness, fatigue, edema (in case of
with arms by the side of her body.
Anaemia complicating pregnancy)
INSPECTION:
History of Present Illness:
Distention, Skin noticed for striae gravidarum and linea
Obstetric Formula
albicans/nigra, Umbilicus, All quadrants move equally with
LMP, EDD, Mode of conceiving
respiration, Previous Caesarean scars, any visible pulsations
If primi ask how many years after marriage
or engorgement of veins, Hernial orifices
UPT done at ________ in _____ months of amenorrhea and
confirmed with a scan at ____ gestational age.
PALPITATION: Consent taken and then Fundal height (in
First Trimester
weeks), Fundal grip (Soft, Non ballotable, Broad mass
Nausea, Vomiting, Morning Sickness, Discharge/Bleeding per
probably podalic pole) , Lateral grip [Left side hard board
vagina, Increased frequency of micturition, Burning micturition,
like mass felt probably baby’s back & On right side multiple
Pain abdomen, Fever with or without rashes, Tetanus Toxoid, Folic
fetal parts felt], First Pelvic Grip [hard ballotable, mass
Acid Tablets, Teratogenic drug usage, Scan – Dating scan and
probably cephalic pole] Second Pelvic Grip.
Nuchal Translucency scan, Exposure to X-Ray
AUSCULTATION: Along the spinoumblical line on the side of
Second Trimester
the spine
Time of onset of Quickening, Discharge/Bleeding per vagina,
Per Vaginal Examination – NOT done
Infections/ Fever/ Rashes, Folic acid and Iron Tablets, Pedal
Edema, Calcium Tablets, Tetanus Toxoid, TIFFA [Targeted imaging
OTHER SYSTEMS:
for foetal anomalies] scan,
CVS- Normal S1 S2 heard, No murmurs.
Third Trimester
Respiratory: BLAE + Normal vesicular breath sounds, No
Continued perception of quickening and its frequency, Discharge/
adventitious sounds
Bleeding per vagina, Burning micturition, Pedal edema, Folic acid,
CNS- No Facial asymmetry, all reflexes are normal
Iron, Calcium tablets, Frequency of Antenatal check-ups, Scans
PROVISIONAL DIAGNOSIS:
A 22 yr Old Primi with term gestation with fundal height
PAST HISTORY: corresponding with gestational age with Hypertension
Past Obstetric History with the outcome, and development history complicating pregnancy, With No signs of imminent
and immunization history of each child eclampsia
-Any H/O HTN, DM, CAD ,TB, Hypo/Hyperthyroidism/ Epilepsy/ A 25 yr old Pregnant women with G3P2L1 came with
Asthma/COPD/ / Blood transfusions uncomplicated breech presentation for safe institutional
Past Medical & Surgical History delivery

Drug and Treatment History: H/O previous surgery for breast NOTES:
Marital History:
Years of marriage, Consanguinity, Husband living with patient or
not, Contraception, Infertility

FAMILY HISTORY:
None of the patient’s parents, siblings or first degree relatives have or
have had similar complaints or any significant co morbidities.
Any H/O twins, congenital anomalies.

Menstrual History: Age of menarche, Duration of cycle, Bleeding

PERSONAL HISTORY: [Important]