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Discipline

: Obstetrics & Gynaecology

Sub Discipline

: Obstetrics And Gynaecology

Document Title

: Obstetrics Outpatient Assessment Note

PREGNANCY

Present Pregnancy

Last Antenatal Follow Up

Never Booked

MCHC

Oher Government Hospitals

Private GP

Private OBGYN

Hospital

Others, specify

Presenting Complaint

None

Abdominal Pain

Contractions

Premature contraction

Regular contraction

Nausea and vomiting

P/V bleeding

P/V staining

P/V discharge

Show

No fetal movement

Reduce Fetal Movement

Leaking Liquor

Giddiness

Headache

Heart Burn

Gastritis

Fainting attack

Blurring of visions

Epigastric pain

Lethargy

Frequency of micturition

Liver Impairment

Difficulty in Breathing

Dysuria

Breathlessness

Backache

Leg pain

Calf pain

Anaemia

Postdate

Uncontrolled BP

Uncontrolled blood sugar

Others, specify

GENERAL EXAMINATION

Vital Signs & Other Observations

Pallor

Nil

Slight

Moderate

Severe

Others, specify

Comments

Oedema

Nil

General

Pedal

Sacral

Others, specify

Comments

Jaundice

Nil

Mild

Moderate

Severe

Others, specify

Comments

Hydration

Well hydrated

Mildly dehydrated

Moderately dehydrated

Severely dehydrated

Others, specify

Comments

Varicose Veins

Nil

Lower Limb

Vulval

Others, specify

Comments

Thyroid

Normal

Enlarged

Others, specify

Comments

Oral Cavity

Healthy

Unhealthy

Few dental caries

Others, specify

Comments

Cardiovascular

NormalAbnormal

Respiratory

NormalAbnormal

Neurological

NormalAbnormal

Breast

Please Update Method

Lymph Nodes

NormalAbnormal

Peripheral Pulses

NormalAbnormal

Gastro - Intestinal

NormalAbnormal

Liver

NormalAbnormal

Kidney

NormalAbnormal

Spleen

NormalAbnormal

Skin

NormalAbnormal

Eyes

NormalAbnormal

Ears

NormalAbnormal

Psychiatric

NormalAbnormal

General Examination Comments

Abdominal Examination

Abdomen

Comments

Fundal Height (Weeks)

Symphysis Fundal Height (cm)

No Of Fetuses

Liquor Volume Estimation

Normal

Excessive

Reduced

Others, specify

Comments

Fetal Lie

Comments

Presenting Part

Comments

Engagement

Comments

Fetal Heart Rate

Present

Absent

Others, specify

Comments

Fetal Movement

Estimated Birth Weight (kg)

Abdominal Examination Comments

Vaginal Examination

Vulva

Normal

Varicose veins

Warts

Ulceration

Warts with ulcer

Herpetic lesions

Mutilated

Others, specify

Comments

Vagina

Normal

Septum

Stenosis

Discharge present

Inflamed

Cystocoele

Rectocoele

Enterocoele

Vaginal cyst

Others, specify

Comments

Discharges

Leaking Liquor

Clear

LMSL

MMSL

TMSL

Show mucus with blood

Fresh blood

Yellowish discharge

Greenish discharge

Curd-like discharge

Urine

Nil

Others, specify

Comments

Bishop Score

Dilatation Of Cervical (Cm)

Length Of Cervix (Cm)

Consistency Of Cervix

Position Of Cervix

Bishop Score

Presenting Part

Membrane

Comments

Arm

Comments

Liquor

Normal

None

Minimal

Excessive

Clear

LMSL

MMSL

TMSL

Foul smelling

Blood stained

Others, specify

Comments

Position Of Vertex

OA

LOA

ROA

OP

LOP

ROP

LOT

ROT

Others, specify

Comments

Caput

None1cm2cm3cm

Comments

Moulding

None++++++

Pelvic Assessment

Adequate

Not Adequate

Borderline

Others, specify

Comments

Other Findings

DIAGNOSIS

Diagnosis

Concurrent Illnesses

Co-Morbidities

Associated Problems

Risk

LowHigh

Comments

ANTENATAL HYPERTENSION

Type - Antenatal Hypertension

Pregnancy-induced hypertension

Pre-eclampsia

Impending eclampsia

Essential hypertension

Renal disorders

Adrenal disorders

Connective tissue disorders

Uncertain

Others, specify

Symptoms

None

Giddiness

Headache

Convulsion

Epigastric pain

Nausea and vomiting

Vomitting

Blurring of visions

Floaters

Restless

Others, specify

Signs

None

Hyper-reflexive

Clonus

Restless

Agitation

Convulsion

Coma

Others, specify

Functional Changes

Impaired renal function

DIVC

Deranged liver enzymes

Proteinuria >300mg / 24 hr

Proteinuria >2 ++

Oliguria

Anuria

Others, specify

Antenatal Hypertension - Management

Conservative

Oral anti-hypertensive

Intravenous anti-hypertensive

Intravenous sedative

Mg Sulphate regime

Immediate delivery after control of BP

Induction of labour

Elective ventilation

Others, specify

Place Of Management

Obstetrics Ward

Labour ward

HDU

ICU

CCU

PAC

Clinic

Others, specify

Hypertension - Ward Urine Protein

Nil

1 +

2 +

3 +

4 +

Trace

Comments

Antenatal Hypertension-Outcome

Delivered

Transferred to Obstetrics ward

Transferred to labour ward

Transferred to ICU

Transferred to HDW

Transferred to CCU

Transferred to other ward

Expired

Others, specify

Comments

HEART DISEASES IN PREGNANCY

Heart Lesions

Ischaemic Heart Disease

Rheumatic heart disease

Mitral stenosis

Mitral incompetence

Aortic stenosis

Aortic incompetence

Tricuspid stenosis

Tricuspid incompetence

Pulmonary stenosis

VSD

ASD

PDA

Pulmonary hypertension

Eisemenger's Syndrome

Left-to-right shunt

Uncertain

Others, specify

Heart Disease - Nyha Class

1

2

3

4

Heart Disease Symptoms

Dyspnoea

Exertional Dyspnoea

Paroxysmal Nocturnal Dyspnoea

Chest Pain

Chest tightness

Cough

Chest infection

Orthopnoea

Giddiness

Palpitations

Edema

Others, specify

Comments

OTHER PROBLEM IN OBSTETRICS

Systemic Disease

Asthma

Tuberculosis

Diabetes Mellitus

HIV positive

AIDS

Superficial thrombophlebitis

Deep vein thrombosis

Pulmonary Embolism

Iron deficiency anaemia

Folic acid deficiency

Thalassemia minor

Thalassemia major

Beta Thalassemia

Alpha Thalassemia

Sickle-cell anaemia

Idiopathic Thrombocytopenia Purpura (ITP)

Urinary Tract Infection (UTI)

Renal diseases

Epilepsy

Hepatitis A

Hepatitis B

Hepatitis C

Acute fatty liver of pregnancy

Gall stones

Hyperthyroidism

Hypothyroidism

Gonorrhoea

Syphilis

Toxoplasmosis

Rubella

Cytomegalovirus

Herpes simplex

Herpes zoster

Varicella zoster

Psychiatric Illness

Depression

Schizophrenia

Bipolar

Others, specify

Ward Investigations

Urine ketone

Urine protein

Urine glucose

Blood Glucose

Comments

RESULTS REVIEW

Comments On Investigations

Comments On Ultrasound

Comments On Histology

Comments On Problems In Obstetrics

MANAGEMENT

Plan

Admission

Discharge

DAMA

Home leave

Medical leave

Ultrasonography next F/Up

Daycare surgery

LSCS

Gynae operation

Specify

Review of investigations

Admission when in labour

Follow-up with own doctor

Follow-up with referring clinic

Regular fetal assessment

Blood sugar profile

Family planning advice

Termination of pregnancy

Genetic counselling

Prenatal counselling

Evacuation of retained POC

Others, specify

Comments

Follow Up

Follow-up in ANC

For ANC booking

Follow-up GYN clinic

Follow-up postnatal

Follow-up when postdate

Follow-up when problems

Follow-up at nearest ANC

Follow-up when investigations ready

Others, specify

Comments

Referral

Outgoing

Comments

Orders

Others, Specify

DISMISSAL ARRANGEMENT

Follow Up Appointment

Please Update Method

Appointment

SIGNATURES

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