OB

Diagnosis NSD: G2P1 (1001) Pregnancy Uterine ____ weeks Age of Gestation by UTZ/LMP, Cephalic in labor/ not in Labor/in beginning labor

Diagnosis LSCS : G2P1 (1001) Pregnancy Uterine _____ weeks Age of Gestation by UTZ/LMP, Cephalic in labor/ not in Labor/in beginning labor, previous CS, 1x 2016, ITRMC

HPI :

Last Menstrual Period :

Past Menstrual Period :
Age of Gestation :
Estimated Date of Delivery :

Prenatal History:
Patient was cognizant of pregnancy at 9 weeks age of gestation due to missed menses from a previously regular 28 to 30 days menstrual cycle. A pregnancy test was done at home
which revealed positive results. Patient claimed that pregnancy was planned, wanted, and without attempts at abortion. First prenatal care was instituted at __weeks age of gestation where
complete blood count, urinalysis and screening for Hepatitis B and Syphilis were done revealing unremarkable results. Subsequent prenatal check-ups were done monthly. The following
medications were prescribed: ___ .
During the second trimester, the patient experienced (infections/any disease entity). There was noticeable abdominal enlargement. An ultrasound was done revealing ___. The
following medications were given: ___.
During the third trimester, the patient experienced (infections/any disease entity). Patient had a repeat ultrasound which revealed __. Medications given included: __.
There were no reported illnesses such as cough, colds, fever, and exposures to viral exanthematous diseases such as measles and chicken pox. No incidence of trauma or fall. No use
of and exposure to cigarette smoke, illicit drug, radiation and toxic chemicals during the entire duration of pregnancy.

OB-GYNE history:
A. Menstrual History
Menarche was at __ years old, with a __days duration, consuming __ moderately soaked regular pads, with associated dysmenorrhea. Subsequent menses occurred
monthly at 28-30 days interval, lasting for 5-7 days, consuming 4 moderately soaked pads per day with associated dysmenorrhea. Interventions for dysmenorrhea includes intake of
paracetamol.

B. OB History : G2P1 (1001)

G1 2014, term, male, Forceps delivery, at SLU-HSH, BW: 3.2 kg, no complications
G2 2017, Present Pregnancy

C. GYNE History
Patient denies any history of foul smelling vaginal discharge. There are no other previous gynecologic illnesses and had not undergone any gynecologic operations.
Patient did not have any Pap smear done and has not received any HPV vaccine or took any hormonal therapy. Withdrawal and abstinence were used as a family planning method.

Past Medical History: (-) Hypertension, (-) Diabetes Mellitus, (-) Asthma, (-) Heart disease, (-) Cerebrovascular Accident, (-) History of trauma/accident, (-) Previous operation (-) Allergies to food
and/or drugs

Family History: (-) Hypertension, (-) Diabetes mellitus, (-) Asthma, (-) Heart disease, (-) Cerebrovascular Accident, (-) Cancer

Personal and Social History: Patient is a non-smoker and a non-alcoholic beverage drinker

PE ADD

Breast:
Symmetrical, (+) hyperpigmented NAC, (-) scars, (-) dimpling, (+) everted nipples, (-) discharge, (-) palpable mass
Abdomen:
Globular, (+) Linea Nigra, (+) Striae Gravidarum, (-) Spider Telangiectasia, Fundal Height of __cm
LM1: Podalic/Cephalic Pole Occupies The Fundus
LM2: Fetal back occupies the L/R maternal side, small fetal parts occupy the L/R maternal side
LM3: Cephalic/Breech, (_) ballotement
LM4: Cephalic prominence ipsilateral to the small fetal parts, contralateral to the fetal back, fetal head is flexed
FHT:___bpm
Genitalia: Grossly female, (+) Chadwick’s sign, (-) discharge
Internal Exam: Admits two fingers with ease, __cm cervical dilatation, __% effaced, cephalic, station __, (_) BOW

GENERAL SURVEY:
Awake, not in cardiorespiratory distress, good activity, good cry and good muscle tone

SKIN:
No jaundice, no cyanosis, pinkish, smooth and moist skin, with few, thin lanugo over most of the body surface area; warm to touch
HEAD/NECK:
No gross deformities, non bulging or sunken anterior fontanel, anicteric sclera; formed and well curved pinna, firm with instant recoil, no alar flaring, grunting, patent nares, with no nasal
discharge, and no ear discharges; moist lips and buccal mucosa, no circumoral cyanosis, no cleft palate/lip; no neck mass seen and palpated
THORAX:
Symmetrical chest wall expansion, no lagging, no subcostal and/or intercostal retractions, clear breath sounds; raised areola, 2-3mm bud, no discharges noted; (-) heaves, (-) thrills, normal heart
rate with regular rhythm, no murmurs
ABDOMEN:
Globular, non-distended, rare visible veins, umbilical stump intact with no signs of infection, normoactive bowel sounds, tympanitic, soft, no masses/organomegaly
Genitalia:
Grossly male, no discharges
Anus:
Patent, no sinuses, no fistula, no bleeding
Extremities:
Symmetrical, complete set of digits and toes, no club foot, with pinkish nail beds, creases over the entire sole were noted, capillary refill time of 1 to 2 seconds
Neurological Examination:
Motor: active limb movements, normotonic and symmetric
Sensory: cries to painful stimuli
Reflexes: positive rooting and grasp reflex, Babinski, moro/startle reflex and sucking
Immediate Neonatal Period
APGAR Score: __ and __
Anthropometric Measurements:
Birth Weight:
Birth Length:
Head Circumference:
Chest Circumference:
Abdominal Circumference: