OBGYN Case Study

Home Blog Uncategorized OBGYN Case Study

OBGYN Case Study

OB History and PE

CHIEF COMPLIANT: Vaginal bleeding in pregnant patient

 

__ Decreased Fetal Movement

__ Observation Evaluation

__ Vomiting, Unspecified

__ Onset of Term Labor @ ______

 

  • Fetal Status thru Diagnostic Test:   _ Amniocentesis      _ NST   _ US

 

  • Obstetric Complications (see below):

__ Preterm Labor @ _____;     __ SROM  @ ______ ;  __Vaginal bleeding   @ __

 

  • Medical Complication (see below):

__ Hypertension      __ Gestational DM   __ Infections   __Thyroid   ___Respiratory    ____other:

 

  • Trauma (see below):

__ Falls    __ Physical violence   __ Other: _____________________________

 

__ Admit: (circle)     Induction    C/S   __see diagnosis

 

Indication Complication/Trauma: _______________________________________________

 

OBSTETRICAL HISTORY/PRENATAL CARE:

__Prenatal Care:              __ Yes                                  __ No^    __ OBCL   __ LBPH    ___ WNC    ___ WILM CL   __ HCP

__Prenatal Records Available    __ Yes/Reviewed                  __ No^ Comment’s:

__ Walk- in

LMP: ____/ ____/_____ EDC by LMP: ____/ ____/_____ Final EDC __ LMP __ US       Final GA: ____ wks. (<20WKS^)

US: ____/ ____/_____ EDC by US: ____/ ____/_____ G: ____ P: ____ T: _____ Preterm: ____ SAB: _____ TAB: _____ L: _____

Previous C/S: __ NO __YES X____ When: ____/ ____/_____

Physical Examination:

Vital Signs:  Temp _____   BP ____   PR _____   RR______   Weight ______   Height _____

General assessment:

Cardiovascular:

Respiratory:

Breast:

Abdomen:  Fundal height:            FHR:          Fetal Movement:

Pelvic Exam:

Lab and Screening Result:

 

Assessment:

 

Plan:

 

References:

Add comment

Academic Research Pro