Medad How To Write An OBGYN Sheet

How To Take An OB/GYN Sheet?
2011/2012
Table of Contents
Table of Contents ................................................................... 1
Before you begin ...................................................................... 2
1-Personal history ................................................................... 3
2-Complaint and history of present illness .......................... 5
3-Past history .......................................................................... 6
4-Family history ....................................................................... 7
5- Menstrual history ............................................................... 8
6-Obstetric history ............................................................... 10
7-Contraceptive history ........................................................ 12
8- Sexual history................................................................... 12
Complaint and history of present illness............................. 14
I)HISTORY OF PRESENT ILLNESS IN GYNECOLOGY SHEETS ............... 15
1-PROLAPSE............................................................................................................... 19
2-BLEEDING ............................................................................................................... 21
3-POST MENOPAUSAL BLEEDING........................................................................................ 23
4-INFERTILITY ............................................................................................................. 24
5-GENITO-URINARY FISTULA ............................................................................................ 27
6-PELVI-ABDOMINAL MASS ............................................................................................. 29
7-AMENORRHOEA ........................................................................................................ 30
II)HISTORY OF PRESENT ILLNESS IN OBSTETRICS SHEETS .............. 34

1-DIABETES WITH PREGNANCY .......................................................................................... 38
2- HTN WITH PREGNANCY .............................................................................................. 40
3 PREVIOUS CS ......................................................................................................... 41
4-ANTEPARTUM HAEMORRHAGE ....................................................................................... 42
5- HABITUAL ABORTION AND IUFD .................................................................................... 43
6 HEART DISEASE WITH PREGNANCY ................................................................................. 44
7- RH INCOMPATIBILITY .................................................................................................. 45
Provisional diagnosis ............................................................... 46

List of abbreviations.............................................................. 47
Medadteam.org
More than you dream
2011/2012
Before you begin

History taking is very important in reaching a provisional diagnosis which is the first
step in clinical assessment of a case as well as its proper management .so it is
essential for a medical student to be a good history taker.
In OB/GYN, history includes 8 important items:
1. Personal history
5. Menstrual history
2. Complaint and present history
6. Obstetric history
3. Past history
7. Contraceptive history
4. Family history
8. Sexual history
In this note each of the previous items will be discussed in 4 parts
Information needed to be collected
How to ask patient in language she understands
How to write information you gather as a paragraph
Some questions you may be asked in the exam
The way in which history taking is demonstrated in this note isnt mandatory or
obligatory, it is just an illustration and you can add or modify in it according to the
situation and your view.
Not only is data collection from patient but also its presentation and interpretation
is important. So try to be clear, precise and confident while presenting your case.
It is needless to mention that history taking is a skill that can be gained by training
rather than an innate talent, so it is extremely important to train yourself on history
taking along your round, the more you train the more fluent and confident youll be at
the exam.
It is strongly recommended to revise the following topics before your clinical exam
as some examiners may ask you some theoretical questions
Gynecologic history and examination
Contraception and family planning
Physiology of menstrual cycle
DD in gynecology
Amenorrhea
Diagnosis of pregnancy
Anovulatory disturbances
Abortion
Clinical problems and disorders of
Antepartum hemorrhage
menstrual cycle
Hypertensive disorders
Pelvic organ prolapse
DM
Uterine fibroids
Cardiac diseases
Genito-urinary fistulas
Rh isoimmunization
Infertility
CS
Medadteam.org
More than you dream
2011/2012
1-Personal history
Name
Age
Marital status
Gravidity and parity
Occupation
Residence
Special habits of
medical importance
Husband history
o Name
o Age
o Occupation
o Special habits

) (

"! #"
)"('&($%
),-".
0 o
(3 % 6" 6 8 ,- o
. & 9: 6
.

$<, > =
o
?! @ o
( )6 ,A
@ o
"!& # o
#B - $D o
#B - D" "E F3
, % - " . $. o
____________________
NB:
In obstetrics sheets we say gravida instead of gravida .
If the husband dies or she is divorced, mention it.
Gravidity = full terms +pre terms +abortions
Parity =full terms +pre terms
In case of infertility sheet youll ask about more details in husbands history
(see later)
____________________
(..Name..) is (..age..) years old, she (is single/has been
[married/divorced/widow] for years/), she is (gravida..para../nulligravida/
gravida.nullipara) with. living offsprings .males and ..females and the
youngest is ..years old. She is (housewife/..) and she lives in .. , she (has no
special habits of medical importance/has been smoking for .years with
average .cigarettes per day/has been drinking alcohol for years). Her
husband is (..name..), he is a (..age..) years old (..job..), he (has no special habits
of medical importance/is smoker).
______________________
Medadteam.org
More than you dream

ORAL
2011/2012
QUESTIONS
Why you asked about:

o Name
- To be familiar with the patient
- To avoid misnomer
- To fill hospital records and facilitate follow up
- To know the cultural background of the patient
o Age
- Some diseases are common in certain age groups
Fibroids 35 -45 y
Cancer cervix 40-50 y
Bleeding
o NewbornEstrogen withdrawal
o <9y precocious puberty
o Peripubertal DUB
o 20-40yabortion- ectopic- V.mole-PCOS- OCPFibroids
o Perimenopausal DUB
o Postmenopausal considered endometrial carcinoma
till proved otherwise
- Diagnosis of certain condition depends on age amenorrhea
- Treatment depends on age
Ovarian tumors
o Young patient ovarian cystectomy
o Old patient panhysterectomy
- Prognosis depends on age fibroids
- IN obstetrics
<20y
o During pregnancy: more liable to preterm labor,
V.mole
o During labor :more liable to PPH
>35y
o During pregnancy: more liable to preeclampsia, DM,
V.mole and congenital anomalies
Medadteam.org
More than you dream
2011/2012
o Occupation
- To know social class and level of education
- Some diseases are job related (radiation exposureteratogenic
/ healthcare workersinfectious diseases
o Residence
- To know social class and environmental background
- To contact the patient for follow up
- Some diseases are endemic (TB, bilharziasis)
o Marital status
- No PV in virgins
- May affect the choice of treatment
o Gravidity and parity
- Long period of infertility followed by pregnancy precious baby
- May help diagnosis
Low parityendometriosis - fibroid
High parity prolapse cancer cx
- May affect ttt
o Special habits
- Smoking Increase incidence of cancer cx, IUGR, IUFD, PROM,
preterm labor and accidental hge.
- Alcohol IUGR, fetal alcohol syndrome and fetal mental
retardation
- Drug abuse STDs, UTI, fetal and neonatal dependence and
withdrawal and increased incidence of congenital anomalies,
IUGR and IUFD
************************
2-Complaint and history of present illness

Mentioned later
************************
Medadteam.org
More than you dream
2011/2012
3-Past history
Similar condition
Diseases (DM, HTN,

CVD,TB and HCV)
Operations(time- placecomplications)
Drug intake and drug

allergy
Radiotherapy and
hormonal therapy
in obstetrics sheet
o Trauma or
diseases of spine
and pelvis
o Blood transfusion
o Congenital
anomalies
contraception
& 9: A I#6

-"E A = D " . o
6" D" $.L. . F : I N!O
P". $. o
<" Q" #. D o
( . ' & o
& 9: 6 6
&#. & ' P". $% =" 6 6 o
6R R
6T". (' D"
0 o
$. <
RB E,. D
" (" . # o
,Q % <& ' 9: 6
0 D & .' % %R & 9: " 0E &
N0 > R 8
,#
=% >9A &
& 6Q V6 .W"&
____________________
NB
Some doctors prefer to add the contraception in the past history
-ve items are mentioned collectively after +ve ones which are mentioned in
details
____________________
She has a past history of similar condition ..years ago for which she (took
../madeoperation)and there was(__/no) improvement.
She has history of (..DM..) .years ago for which she takes . And the
condition was (__/not) controlled with (__/no) complications (as)
She has a history of operation in (..hospital..) .years ago with (__/no) intra
or post operative complications (as .)
She has history of (..drug..) intake for years to treat and she is (__/not)
allergic to ..
Medadteam.org
More than you dream
2011/2012
She has history of (radio/ hormonal) therapy .years ago to treat.

She has history of (trauma /blood transfusion) ..years ago and (her blood
group is./she is Rh .)
She has no past history of .. , , and .
______________________
ORAL
QUESTIONS
Why you asked about:

o Similar conditions
- Because some conditions are recurrent as prolapse
o Operations
- To know if the condition is recurrent (prolapse may recur after
repair with worse prognosis)
- To exclude presence of adhesions as a cause of infertility
o Trauma or diseases of spine and pelvis
- To exclude contracted pelvis
o Blood transfusion
- To exclude blood borne diseases as HCV ,HBV etc
- To know her Rh and exclude sensitization
************************
4-Family history
Similar condition
Diseases (DM, HTN, CVD)
Consanguinity
IN GYNE
o Malignancy
IN OBS
I#6 X(E @ R %

$.L. . F : N!O I @ R %
F: ,A E F3 F:
Y : > 3 @ R %
,
=% (3& 9:
Z, [ D R %
& 6
6< A R %
o Twins
o Congenital anomalies
o
preeclampsia
____________________
NB: -ve items are mentioned collectively after +ve ones which are mentioned in
details
____________________
Medadteam.org
More than you dream
2011/2012
There is family history of as her (..mother) also had ..

There is no family history of . ,.. , .. and
**************************
5- Menstrual history
A
)6T". -"
Rhythm
( R % , ), $.), & -"
Duration
"(&
Length
, % . "! = : " L" 6
Amount of blood loss
("% &' ! % & 9I( BE " =% :"
Intermenstrual
D>
< \
Q" N0E I L" % % $ $
symptoms
& 9:
\ <Q"
Dysmenorrhea
$% V6< $% o
1st of LMP
" . "= P". 9 " : & . o
Menopausal for.
@R. E % o
P". D % ,
" . $. R3:
_____________________
NB: In bleeding sheet take menstrual history before onset of condition
_____________________
Her menarche occurred at the age of y and since then her cycles were
(regular/ irregular) occurring every .days and last for days with bleeding of
(average /scanty /excessive) amount as she changes .pads/day. It is (__/not)
associated with Intermenstrual (pain/discharge /spotting). It is (__/not)
associated with (__/spasmodic/congestive) dysmenorrhea. First day of her
LMP was on../../.
Menarche
If menopausal +she is menopausal for .y

In OBS +so her EDD is and her GA is provided that her last 3 cycles
are regular occurring every 28 days without use of contraceptives in last 3
months
In 1ry amenorrhea she has no menarche up to the moment
_____________________
Medadteam.org
More than you dream

ORAL
2011/2012
QUESTIONS
What is normal and abnormal:

Menarche 10-14 years
- <10precocious
puberty
- >16y 1ry amenorrhea
Rhythm
Within 1w before or after expected

day
Length
28d 7d
- <21d polymenorrhoea
- >35doligomenorrhoea
Duration 4d 2d
- <2d hypomenorrhoea
- >6d menorrhagia
What is the importance of intermenstrual symptoms?
o Their presence is suggestive of ovulation
Compare between spasmodic and congestive dysmenorrhea?
Type of
patient
Type of pain
Site
Radiation
Onset
Peak
End
Cause
ttt
Why
o
o
o
o
Spasmodic
Young nulliparous
Congestive
Middle aged multiparous
Intermittent colicky
Lower abdominal and
suprapubic
Lower back and inner thigh
With onset of menstruation
End of first day
By second day
Continuous dull aching

Lower abdominal
Back
Before menstruation
Just before menstruation
With onset of
menstruation
Occurs only in ovulatory cycles Pelvic congestion
Anti prostaglandins and
ttt of cause
st
you asked about 1 day of LMP
To exclude pregnancy
Most gynecological procedures are done post menstrual to decrease
congestion and blood loss
Some procedures are done pre menstrual as PEB
To calculate GA and EDD in case of pregnancy
Medadteam.org
More than you dream
2011/2012
What is the menstrual index?

o Duration/length of the cycle (eg 4/28)
What are characteristics of menstrual blood?
o Color Dark red as the vaginal acidity acting on some blood turn its
Hb into met-Hb (Brown).
o Odor Offensive due to decomposition of blood elements mixed with
sebaceous secretion at the vulva.
o Clotting Normally no clots due to fibrinolytic activity of the
endometrium
o Composition Endometrium , RBCs, cervical mucus, cervical and
vaginal epithelium and enzymes
************************
6-Obstetric history
Obstetric code
Full term Pre term Abortion Living

>37w
28-37w <28w
Obstetric table
NO
Date
Duration Pregnancy
disorders
-Full
Bleeding
term
HTN
PE
Preterm DM
UTI
Mode of
termination
-Vaginal
delivery
-CSplace
/indication/
complication
-abortion
Hospital -Hge
spontaneous/ home
stillbirth -Sepsis
induced/ SE clinic
-IUFD
Bleeding
UTI
Place
Outcome Puerperium lactation
Hospital -Living
home
/dead
clinic
-Male/
female
-Free
-PPH
-puerperal
sepsis
-Breast
feeding
for y
-Bottle
feeding
because
_____
Last labor
Last abortion
Blood group
contraception
Medadteam.org
More than you dream
2011/2012
: . & 9: 6
I= # % N0 % o
I= # % LE
R. % ,LE
= > o
$#
= o
" :, >
F" P".& 6 & ,0 0
&6 & #. & '&
P".& 6Q[ LE A & o
&6Q V. N!O & 6
6< A o
& 6 I A o
,9 -. % "=A o
( B ,9 R93 & & >
' : , > o
R ,3 . "W & 0E "-" 6R R & #. = & '& E o
6R
$% o
,=B E > %" . '& N0< -E
,# % & LE . R . . LE &(_ & o
LE ," @ , LE & o
( #"<6 > 9 % &' o
N0< R [T 6 & o
N0< R &#. & '& N0< R % I LE & o
(3 -E
=
9 o
?(A> , R &#. '
=% o
F9< %@ 6 > , R > , %, (3> $. o
N0 > R &#. '
,9 -. % ( "=6 A o
N0 > R 8 0 D & .' % %R & 0E "-" [ LE ' o
(P"."=
6_%) "=
RO ? VO > R93 (3" & RO
O& #. & '& o
& 6Q V6 " .W"
___________________
NB: Some doctors prefer to add the contraception in the obstetric history
___________________
Her obstetric code is../../../..
Her (1st/ 2nd/3rd) pregnancy was (in ./y ago)with (no remarkable antenatal
events/ DM/.). It was terminated (at full-term/ pre-term/w) by (VD/CS
because with [__/no] complications /[spontaneous/induced] abortion
[__/not]followed by SE) in (.. hospital/ clinic / home).
Medadteam.org
More than you dream
2011/2012
The outcome is (living [male/female]/ IUFD /stillbirth), and puerperium was

(free /complicated by [puerperal sepsis /PPH] and the baby is (breast fed for
y with [__/no] breast complications/ bottle fed for..y because)
Her last labour was y ago while her last abortion was y ago. And (her blood
group is../ She is Rh ..)
************************
7-Contraceptive history
Method
When started and when stopped
Why stopped (seeking fertility/complications)
& 6Q V6 " .W"

" ." _ "= . =
= . &#. & '&
____________________
NB
Some doctors prefer to include the contraceptive history as a part of past
or obstetric history
CCP
&6Q V. ,9 IUD
NB/ F, Tubal

ligation
Q >,<9 Safe period
-
FE N
O ,9 SD
.>" %
implants
Q $. 0 condom
:
Injectables ,=B 3 & $0 Vaginal
rings
____________________
- She didnt use any contraceptive method
- She used (..method..) after .. for .y with (__/no) complications
(as..)and she ( stopped/ removed) it (seeking fertility/ for complications)
***********************
Minipills
8- Sexual history
Frequency/regularity
Timing
Sexual problems (dyspareunia/
frigidity/ vaginismus)
T"E &'Q & ,9> % 6- .

"%< ,A
d,9"" % % 6A &'Q
"A &
6-& #.
% &
_____________________
Medadteam.org
More than you dream
2011/2012
She has sexual intercourse times/week with (__/no) sexual problems (as..)
_____________________
ORAL
QUESTIONS
What is the most suitable frequency of intercourse for a couple desiring

conception?
o Twice /week
o If <2/w more liable to miss the day of ovulation
o If >2/w increased immature forms of sperm
What are the common sexual problems?
Def
Dyspareunia
Painful
difficult
intercourse
Vaginismus
Reflex spasm of levators,
glutei and thigh adductors
on any attempt of vaginal
penetration
Cause -Genital
inflammation
-UTI
-Vaginal
dryness
Frigidity
Loss of sexual desire
-Physiological
(prepubertalpostmenopausalpregnancy)
-Dyspareunia
-Female circumcision
Types -Superficial
-1rypsychological
-Deep
-2ryto dyspareunia
TTT TTT of cause + psychotherapy
Psychotherapy+
Methyl testosterone
**********************
Medadteam.org
More than you dream
2011/2012
Complaint and history of present illness

Complaint is the most distressing symptom which brought the patient to
seek advice
It should be written in patients own words
If > 1complaint arrange according to importance and chronicity.
In obstetric sheets, the gestational age is mentioned in months in the
complaint and in weeks in HPI.
History of present illness includes :
a)
b)
c)
d)
e)
f)
Gynecology sheet
Analysis of the complaint.
Associated gynecological symptoms
(Bleeding - discharge -pain-mass).
Complications and possible cause.
Previous investigations, treatment
and results of each.
Admission and following
investigations and treatment.
System review ( DM & HTN)
Gynecology sheets
1. Prolapse.
2. Bleeding.
3. Postmenopausal bleeding.
4. Infertility.
5. Fistula.
6. Pelvi-abdominal mass
7. Amenorrhea.
Medadteam.org
Obstetrics Sheet
a) LMP, EDD and GA.
b) Review of each trimester symptoms
and warning signs.
c) Analysis of the complaint and
effects on current pregnancy,
complications possible causes.
d) Previous investigations, treatment
and results of each.
e) Admission and following
investigations and treatment.
+Mode and time of delivery
f) System review (DM & HTN)
Obstetrics sheets
1. Regular antenatal care.
2. DM.
3. HTN.
4. Previous CS.
5. Ante partum hge.
6. Recurrent abortion.
7. CVDs.
8. Rh incompatibility.
More than you dream
2011/2012
I)HISTORY OF PRESENT ILLNESS IN GYNECOLOGY SHEETS

A) Analysis of the complaint
Vary according to the sheet see later
~~~~~~~~~~~~~~~
B) Analysis of the associated gynecological symptoms

1) Bleeding:
Onset
Course usually gradual
Duration if <2days hypomenorrhoea & if >6 days

manorrhagia.
Preceding events IUD -Period of amenorrhea hormones

psychic trauma or contact as douching or intercourse
Amount
Color
o Bright red fresh
o Dark red retained before expulsion
Odor
Other symptoms mass + pain
Bleeding from other orifices
Rhythm and relation to menses
L P% [ LE

L P". $.
T". & 0

)
P"9 " L . &9:
, E,. PjD , F,
A , D\
R L , "
" 6-
"!6
V % .
@ L" A % L"
0
E, L P
# " Q
P% E P%
.PE I. $. L
2) Discharge:
Onset, course & duration.
Amount factors increase & decrease
Color
Odor offensive or odorless
Consistency viscid or watery

Other symptomsitching
Associated itching .
Medadteam.org
%
L
& 0" L" P". $.
= 0" L" R. A P% "= 6
) Q= = E,
6 . PR = I6
W6
I E R.
More than you dream
2011/2012
3) Pain:
Site
Radiation backache in prolapse
Severity according to type of analgesic relieving it
Character
If continuous what exacerbate and what relieve
If intermittent what bring and what relieve
Other symptoms Irregular menses , vaginal

discharge , itching infection
P". $. < \

Q"
& 0 L
" P% V6< N9T $%
>
$% E
6 R N< B
>
F3 I<. D"
P,=(?
,3 P ,A,.
>
@ L P F3 -
0 P
>
V. E P%
4) Mass/swelling(fibroid, ovarian tumor):
Site & size
Special character
What increase & what decrease
Possible cause
Complications
RI
& 0 L P".
6- $% ,
0" @ L" A P%
& #. . F9<
_________________
NB Congestive symptoms Prolapse, Pelvi-abdominal swelling
o Pain congestive dysmenorrhea dull aching
o Discharge leucorrhea
o Bleeding menorrhagia
_________________
The condition is( __/not) associated with bleeding of ( acute /sudden
/gradual ) onset , (progressive /Regressive /Stationary) course and .......
duration , (not) proceeded by . , of . amount as she changes .. pads /day
, (bright/dark)red in color with (no offensive) odor , (__/not)associated
with other symptoms or bleeding from other orifices
The condition is (__/not) associated with discharge of (acute /sudden
/gradual) onset, (progressive /Regressive /Stationary) course and .......
duration,(__/not) proceeded by., of .amount, .in color,.. in odor ,... in
consistency ,(__/not)associated with itching or other symptoms .
Medadteam.org
More than you dream
2011/2012
The condition is (__/not) associated with pain of .onset ,. course and

..duration in . (radiated to .. ) ,
(mild/moderate/severe)(colicky/stitching /)(intermittent/
continuous),aggravated by and relieved by . and (not)associated with
other symptoms.
The condition is (__/not) associated with a mass in .. of . onset, course,
duration ,increased by and decreased by . with(__/no)special
characters , probably caused by . and causing .. .
~~~~~~~~~~~~~~~
C) Complication and possible etiology

Vary according to the sheet see later.
~~~~~~~~~~~~~~~
D) Previous investigations and treatment:

P". $% PR' 0 P- . &9: P"
Where?
? ,Q% E, RBm & Q , 6
Investigations done and their results.
"= -"E
Any received medications name
$0 B PD
dose-route-results
-"E A ) P"#.
6 P I#6 # 6 P" 6
Any operations done place-whenR. &' & -"E A P". $%
complications-results
( .
__________________
She sought medical advice ago, in . where investigations in the form of
were done (which shows ./with no available results ). She was diagnosed as a
case of . and was given .with (__/no) improvement of condition (.
Operation was done in .. .ago with (__/no) complications and with (__/no)
improvement of the condition.
~~~~~~~~~~~~~~~
Seeking medical advice, when?
E) Admission:
Date
Investigations done , results
Treatment given or going to be given
Medadteam.org
( P". PL-Q ) P". PR' 0 P"A

"= -"E "= 6 P ? ,Q( P"A 6
P 6R"<" . : = D" P )
_________________
More than you dream
2011/2012
She attended to Kasr El Aini outpatient clinic . ago, where she was admitted
and investigations were done in the form of . (with no available reports ) (
She was given ..) and she was told that she is waiting to do .
~~~~~~~~~~~~~~~
F) System review:
Urinary tract frequency duration- difficult micturation - stress incontinence

GIT nausea - vomiting - dyspepsia - diarrhea - constipation - tenesmus
Blood disorders ecchymosis
chest & heart cough dyspnea- hemoptysis -chest pain
Metastasis
o Lung hemoptysis - dyspnea - chest pain
o Liver jaundice -ascites -right hypochondrial pain
o Bones bony aches - pathological fractures
o Brain headache - increased ICT
DM,HTN
I N!O E A $. I"#"

_________________
System review reveals no other abnormalities
~~~~~~~~~~~~~~~
Medadteam.org
More than you dream
2011/2012
1-PROLAPSE
Complaint:
Sensation of heaviness
Mass filling vagina of duration
Mass protruding from vulva
&0"
E AQ
Q $. E AQ
HPI
A) Analysis of the complaint :
Onset related to recent delivery or menopause
Course progressive
Duration
What aggravates increased intra-abdominal

pressure
What alleviates lying down
&9: F:

E
R &' @ I ) & I#6
(9 P% ,3 >
P".
& 0 L

. P:LQ" 6 )@L" A P%
' ( % P R0"
(
. P." 6) 0" A P%
B) Associated gynecological symptoms see before

=. "% 6 P% P% =o P% VA P%
Backache, pelvic congestion
& 9: VA Q
C) Complications and possible causes
complications
o Urinary ( suggestive of cystocele)
Frequency of micturation.
Burning micturation.
Need to reduce the mass digitally to complete the act of micturation.
Pyelonephritis: fever, vomiting & loin pain.
Urine retention.
Stress incontinence.
o GIT (suggestive of rectocele)
Constipation
Inability to complete the act of defecation unless mass is reduced
digitally.
o Sexual dyspareunia
o Infections suprapubic pain , contact bleeding & discharge

Medadteam.org
More than you dream
2011/2012
Predisposing factors
o Chronic constipation
o Chronic cough
o Successive deliveries especially at home with no proper spacing.
o Abdominal tumors
o Ascites
o Carrying heavy objects
o Trauma (Previous hysterectomy Vault prolapse)
o Congenital weakness of mesenchyme ( Virgins prolapse ) flat foot , varicose ,
hernias
,9 % &#. %
, P% . p9' > " & 6Q P "o
P 6I 0 # : $. R,? P D & >,9 P% : P% o
VA V. A P% VA A & @ 9: P"W o
& @ 9:
% Q ,9 o
P<_R PQI 6 . =, P% o
9 P% &#. < .
6- P% &#.
. % % 6- R
L $_9
(&
,0< F9 %
" =
% P% dR =
>.L. Q $.L. <. o
0 A P #" & @ 9: 0<" A $_9 P% o
, P ,% % o
D) Previous investigations and treatments and their results : see before
E) Admission: see before
F) System review: see before
_______________
She is complaining of a mass protruding from vulva of y duration.

The condition started .. y ago after...... , at the beginning it was small and it ran a
slowly progressive course over . y it reaches the presenting size, it increases on ..
and decreases on .
It is (__/not) associated with pain backache which become worse at the end of the
day , discharge & bleeding.
It is (__/not) associated with urinary symptoms as but no .
It is (__/not) associated with symptoms of rectocele as and /or dyspareunia .
It is (__/not) associated with chronic cough , constipation .
She sought medical advice . .
She attended Kasr Al Aini . .
System review shows no other abnormalities.
Medadteam.org
More than you dream
2011/2012
2-BLEEDING
Complaint:
P
L / [LE $. PI"#"
a)
b)
c)
d)
e)
f)
Regular vaginal bleeding R. P% [LE P -

Irregular vaginal bleeding P % q. / _9W ".
Bleeding between cycles $ [LE
Heavy bleeding between cycles
Vaginal bleeding after intercourse & douchingP 9=6_[ #" 6- R [LE P -
Too frequent menses =# P% . $. " P -"
HPI
Relation to menses
a) menorrhagia
b) &c) metrorrhagia
d) menometrorrhagia
e) contact bleeding
f) polymenorrhoea
Analysis as generalsee before
compare with normal menses in amount & duration
": & . [L
> )T".
. E[ L& 9: F3
, & P-" E
"(&
B) Associated gynecological symptoms : see before

$_9 P% , %
P%
Pain, discharge, abdominal swelling or itching
Complications anemia
Causes
o General coagulation disorders, CVDs, HTN, thyroid disorders, anticoagulants.
o Pregnancy complications (proceeded by a period of amenorrhea and +pregnancy
test) abortion, ectopic or vesicular mole.
o LocalFaulty use of contraception (perforation with IUD/ Breakthrough
bleeding with combined OCP, POP and injectable contraceptives.
o Cervical lesions contact bleeding
o Tumors (Fibroid by sonar & endometrial hyperplasia or malignancy by
fractional curettage )
DDGIT bleeding (piles)- urinary bleeding (urethral carbuncle)
Medadteam.org
More than you dream
2011/2012
& 9: P" 0E D"

, D" <_ . R - Q . ,A P"T >
Q A . A F 0 O P% %% , -= P<Q"
N!O ?
< . ,? P% ! P"T > ) ,- 6Q $., 9' E P"<
( hyper / hypothyroidism ) [ L V. , P%
& 6 9"D P" 6 R3: E 6 ) P% [ L& 9:
[ L& 9: &6Q V. &Z P".W"
6- R [LE -
-" Q E, P" 6
9 P% ~ : ,9 , P% ! : ,9 P% &#. P% ,
Common investigations
o Essential labs
- CBC: RBCs- Hb%- Haematocrete( decreases in acute or
sudden blood loss)- WBCs( increases in blood loss due to
haemoconcentration )
- Coagulation profile
- Liver & kidney function tests
o Ultrasound : pregnancy , IUD displacement or tumors
o Fractional curettage: endometrial hyperplasia.
Common treatments
o Non hormonal : Fe- Folate- Tranexamic acid (,< ): $0 :
[L
o Hormonal ,3 P D\
She is complaining of (menorrhagia / metrorrhagia / menometrorrhagia / contact

bleeding / polymenorrhoea) of y duration.
The condition started .. ago when the patient noticed change in her menstrual
pattern in the form of .. instead of her normal menses which was regular every . d
and lasts for . with amount ( . pads /d)
It is (__/not) associated with pain, discharge, swelling and/or itching.
It is (__/not) associated with symptoms suggestive of (HTN/CVDs/Coagulopathy /
Thyroid disorders) as . .
It is (__/not) associated with bleeding from other orifices .
She sought medical advice . .She attended El-kasr el-eini . .System review shows
no other abnormalities.
Medadteam.org
More than you dream
2011/2012
3-POST MENOPAUSAL BLEEDING

Complaint:
R_: . R P

L
Vaginal bleeding after menopause
HPI
P". $. R3:
, P". $. . A [L
"! 9I . " P%

menses as there is no menses anymore )
R0 [L . & , P% .
B) Associated gynecological symptoms : see before

Complications anemia
! #$% *) ('
Causes
'! +
o General
0! 12 3 313 , -. $
coagulation
$ 6!( # 6(
disorders,
anticoagulants
892 ; .=
CVDs, HTN
' ! 6>$% !'@ A= 6
Thyroid disorders.
.= 6%'; 3 19% )* C
o Hormonal Estrogen
( hyper / DE.! F !'3
replacement therapy.
Duration of menopause
Analysis as general ( N.B. Don`t say relation to
o Local
Senile vaginitis
Retained pessary
Tumors :
premalignant lesions
(endometrial
hyperplasia , CIN )
or malignancies
DD piles or lower GIT, colonic or
rectal cancers
hypothyroidism )
' ! 1 H+
.! I #$' + >=
J9 $ ; 3 F( 3
K
L ; 3
' 6>)= 3 F( 3
1 ! 3 -+ .=
!'3 19%
1 ! ' 3 M 3
1 ! 3 K
! '

Medadteam.org
More than you dream
2011/2012
She is complaining of recurrent attacks of vaginal bleeding after

menopause for . .
She is menopause for . , .. ago she noticed recurrent attacks of vaginal
bleeding of onset and . course (__/not ) proceeded by . , it is of .
amount as she changes pads/day , it is . in color , in odor , and it is
(__/not) associated with other symptoms discharge pain-swelling or
bleeding from other orifices .
It is (__/not) associated with symptoms suggestive of (HTN/ CVDs/
coagulopathy/ thyroid disorders) as . .
She sought medical advice . .She attended El-kasr el-eini . .System
review shows no other abnormalities.
~~~~~~~~~~~~~
4-INFERTILITY
Complaint:
[W q. # A
Failure of conception for y.
HPI
Duration of marriage
Previous conceptions
Start of searching for

conception, use of
contraceptives & regular
marital life
& 9: 6
" .& 6 D , o
) o
: 0 ,-".
( W P% I(
0 ,- R
& 6 VE,. P".W"
,3 P
R. (" ,3 ,A
%<
B) Associated gynecological symptoms : not important

D) Previous investigations and treatments
Medadteam.org
More than you dream
Male
How
Tofactors
Take An OB/GYN Sheet?
2011/2012
o Previous marriage and number of children

o General diseasesDM- HTN-CVD-mumps
o Operationshernia-varicocele when, where
o Exposure to radiation
o Drug intake
o Semen analysis when, results & treatment
Sexual intercourse see sexual history
Female factors:
o Ovarian:
Normal ovulation Regular cycles- Intermenstrual (pain- spotting
discharge) - spasmodic dysmenorrhea- Premenstrual syndrome
(Headache-mastalgia- irritability).
Menopausal symptoms nervousness- hot flushes
Investigations
Folliculometry -PEB
Hormonal profile
o FSH (if highpremature ovarian failure)
o Midluteal serum progesterone
< 5 ng/mlanovulation
5-9 ng/mlovulation but with LPD
>10 ng/mlovulation with adequate CL
ttt: induction of ovulation by Clomid tablets from 2nd day of the cycle for
5 days and follow the response on the folliculometry.
o Tubal:
History of abdominal or pelvic operations.
History of salpingitis (Fever, bilateral lower abdominal pain & offensive
vaginal discharge) or T.B. (night fever, night sweating and loss of weight)
Investigations: HSG, diagnostic laparoscopy.
ttt: tubal insufflation, tuboplasty(surgical or operative laparoscopy)
o Endocrinal:
Hyperprolactinaemia Galactorrhea
Myxedema constipation, increased weight and hoarseness of voice.
Hyperthyroidism intolerance to hot weather, nervousness, palpitation,
decreased weight in spite of good appetite
PCOS or verilizing tumors hirsutism, deepening of voice
o Uterine :
Amenorrhea& hypomenorrhoea
T.B.
D&C, myomectomy or C.S.
Investigations HSG, Hysteroscopy, U/S &PEB
o Cervical & vaginal :
Erosion, vaginal discharge, backache, cautery& dyspareunia.
Investigations: postcoital test.
Medadteam.org
More than you dream
2011/2012
?How To Take An OB/GYN Sheet
,A ,-". E & A =.(3 ?! @

o& ,A @ N!OI F : ,
I . $.L. (#"<. % L-Q6Q
o , 6 &6 &9:@ P% P 'W "% P". $% & '& =. (.
o& ,A "R >RB D =. .,.
,A o ,. &Z & Q &6 P". $% " - " 0 @D
A -"E R & Q &6@ " - & Q Dm P".
6T". _9W ". " VA, P<Q $
\ P<Q" $ N0E "L P%
% &9: "' P<Q ? P% VA
=' P<Q" o P% E,W B 6<A 9' P"0 $., $)
o PD d,9 N# $0 B 6 -"E A
d,9 R". P" 6 o & QE,. P". " - $. . D
&9:
T6 d96
W 6 P" 6 F3
P" 6 6 &9: $_ p"%@ $% P". '& #. =.& R )
R P"W F3 >
A o P% VA(& V. $_9% ="Q E #
N0
& A o L
P" 6 o L RB ' P !9
) FE P". " -
T. P" 6 o _ $ P". $% " -
(E 6 P" 6 o FE " - < 6 P" 6 F3 FE T. $_ p"%
P%% L" $9 ? $. $. P". =E, N9T $" E E PD
=
o <. P% 3,Q ., ! P%',
P"< o $ 9' P"0 E) P 6Q"" q"0. Q " P<Q 9 : 9D "=B
& 9D E L &0
RB P% o _ 6<A P% V P% E,#D',
T. P" 6
E, Q $. PD
" -
P% : A
= P% .L.

P% =T
6-
&9: P" 6 o@ R P

R & Q P" 6 o6- " -
More than you dream
Medadteam.org
2011/2012
She complains of failure of conception for . .

The condition started . ago in the form of failure of conception in spite
of regular unprotected marital life without use of contraception. .
This is the .. marriage of both she and her husband (__/ with children
and the youngest is . )
She started searching for conception .ago when she sought medical
advice and semen analysis of her husband was done ago that revealed (
results. where treatment in the form of was given and the
condition improve).
Sexual history : see before
The condition is (__/not) associated with symptoms suggestive of
(ovarian failure/ovarian factor /tubal factor/hyperprolactinaemia
/thyroid abnormalities/hyperandrogenism/cervical factor)
in the form
of ..)
~~~~~~~~~~~~~
5-GENITO-URINARY FISTULA
Complaint:
continuous dribbling of urine
Failure of voluntary control of urine
,3 P L ,9
,9 P%
IQ 0 .
HPI
Onset , course & duration

Type
o Complete incontinence no desire vesico-vaginal
o Incomplete incontinence occasional desire
Uretro-vaginal
" . I#6
&0" > L"
L E< Q" &
6Q
B) Associated gynecological symptoms :see before
Medadteam.org
More than you dream
2011/2012
Complications
o Vulvitis and pruritis itching , soreness in thigh
and vulva
o Urinary tract infections suprapubic or loin pain
o Renal failure uraemia, oliguria, loss of
consciousness
o Amenorrhea
Possible causes
o Obstetric trauma
prolonged or difficult labor
necrotic vesicovaginal fistula (occurs
after 5 days)
Instrumental delivery traumatic
vesicovaginal fistula (occurs
immediately)
C.S. place, indications &
complications.
o Gynecological surgical trauma Hysterectomy etc.
o Radiation necrosis.
o Pelvic malignancy and abscesses.
$jW( $ : P%

,9 LE I.
9A P% $_9
(& P%
P" 6 P I P% &#. '
, <& 8
I#6 R R_:
> , R I#6
< R". ,3 E
> , P% ,.W"
P(#"<. P% ' : P
&' F9<
6R R & #.
6 R I#6 F3
$_ p"% Q $. E
P% D A
,Q
,Q P RB PD
I#6 6
@ \ R

She complains of continuous dribbling of urine for . .
The condition started . ago in the form of continuous dribbling of urine
after . .
The patient has no desire of micturation
The condition is (__/not) associated with symptoms of (vulvitis /pruritis
/UTIs/renal failure) in the form of .

Medadteam.org
More than you dream
2011/2012
6-PELVI-ABDOMINAL MASS
Complaint:
Abdominal swelling
D,(. P_ / 9I" P_ / P_ P%
HPI
A) Analysis of the complaint : analysis of masssee before
B) Associated gynecological symptoms :see before
,

,
malaise.
/ +, / "#$
( &

Urinary symptoms difficulty, frequency,
-
.
/0
,0"
duration, loin pain.
, 7#3
. , 8+ , 12 334 7-
GIT symptoms nausea, vomiting, heartburn,
:( , 93,
constipation, diarrhea & tenesmus.
/; 7< =( &/; " 2>

T.B. night fever, night sweating & weight
7?
0:(

@A
loss.
0
Pressure symptoms dyspnea, palpitation,
; + " C"
:0" A-"
:0"
L.L.edema, dyspepsia & frequency.
& E 7#" #
;
Malignancy symptoms rapid growth, wt.
2
F<2
:" G/"
loss, cachexia, unilateral L.L. edema.
1-0 "
#$ 7$
.

Metastatic symptoms:
7& +
0/
o Lung: chest pain, dyspnea & haemoptysis
$ 7G
( &

o Liver: jaundice, Rt. hypochondrial pain &
/-/
deep color urine.
;;4 7H7I 8+ , 30:( 7$

o Brain: headache, projectile vomiting &
J/#
blurred vision.
: 3K
="
:0"
o Bone : Bone aches & pathological
L/:" LM 7#"
fractures
/;3
0;3

o Breast
7O
Constitutional symptoms fever, headache,

Medadteam.org
More than you dream
2011/2012
She is complaining of abdominal swelling for . .
The condition started . ago in the form of a mass of (see before..).
The condition is (__/not) associated with ( pain /discharge /bleeding ) in the form
of .
The condition is (__/not) associated with constitutional (urinary/ GIT/ TB/

Pressure/ Malignancy/ Metastasis) symptoms in the form of
She sought medical advice . .She attended El-kasr el-eini .

.System review shows no other abnormalities.
~~~~~~~~~~~~~~~
7-AMENORRHOEA
Complaint:
1ry amenorrhea
Failure of menarche
D q A.
HPI
A) Analysis of the She started
complaint
investigations for
delayed menarche
at the age of . .
2ry sexual
characters ( pubic
and axillary hair &
breast
development )
B) Associated
Not important
gynecological
symptoms
Caus outflow
-imperforate hymen
es
tract
-transverse vaginal
septum
-vaginal atresia
-cervical absence or
Medadteam.org
2ry amenorrhea
Cessation of menses for . >3-6
m
=B.....=0 L _ / R_:
The condition started . ago.
Not important
-Ashermann syndrome (Surgery

[over curettage/ CS/
myomectomy]-IUD-Infections[TBpostpartum or post abortive
sepsis]
More than you dream
Ovaries
Pituitary
Hypothala
mus
General
C) Complications
and possible
causes
stenosis
-Gonadal agenesis
(Rokitanesky $)
-Androgen
insensitivity $.
-Turnerphenotypic
characters +
karyotyping
2011/2012
-Functional ovarian tumors

virilizing (hirsutism, hoarseness,
acne)
-PCOS virilizing(hirsutism,
infertility , obesity)
-Ovarian failure(menopause
-premature menopause [mosaic
tuner / mumps /radio-chemo
therapy/oophrectomy])
-Prolactinoma&
hyperprolactinaemia
-Empty sella $(surgical /traumatic
/irradiation/ congenital) CT is
diagnostic
-Sheehans $ ( failure of lactation
after delivery )
- Kallmann`s $
-Stress, rapid wt loss, severe
(congenital GnRH
exercises , Drugs
deficiency + anosmia ) -Destruction by (Tumors /
meningitis /encephalitis/ fracture
base)
Chronic malnutrition / Endocrinal
symptoms of :
a. cryptomenorrhoea cyclic lower abdominal pain ,
abdominal swelling & attacks of urine retention
b. Pituitary adenomaheadache, projectile vomiting &
visual disturbance.
c. Psychological disturbance
Exercises, wt. loss.
Medadteam.org
More than you dream
Hormonal assay
D) Previous
investigations
U/S
and treatments
and their
results
E) Admission:
F) System review:
see before
P P":,
P".? ,Q(
ER P% RB = o
N) Q RB =o
PR93 =o ?
$_9! (& 6 P<Q"
"( E P% = B &
9" P<Q" $_9 P%
,9
V. 6" B ?P%
6"<. ~: 8
$. ,! POR""
. 9:
EQ".
6 P" 6
E,. RB PD
P(#"<. P% PL-Q F3
& @ 9: '
"= 6 P ? ,Q(
Medadteam.org
2011/2012
operations, radio or
chemotherapy
Drugs, hormones, OCPs.
IUD
TB
Last delivery ( sepsis or PPH)
Hyperandrogenism
Premature menopause
Hyperprolactinaemia
Hormonal assay
U/S
Hysteroscopy
CT
P". $. R3:
, X(E 668 " &6 \q"< .
_ P% & 9 _ , VA
& 6 9"D P" 6 F3
"(E P% = B & $_9! (& 6 P<Q"
,9 9" P<Q" $_9 P%
~: 8 V. 6" B ?P%
6"<.
V_0 . & 9: " A P%
RB 6 D 6 .
V_0 . &9:
V_0 . &9: E,. D"
F, P"9& 6Q V. ,9
& 9: 'P(#"<. P% PL-Q
P6 [ LE A > R R_:
> , R (
P% PR9_ $ RB ,=o P"T >
! ,? B
V. 6" "9: B P% =? P%
L%E 9'
? $. L" $9 % P%
More than you dream
2011/2012
, E,.& Q ? ,Q% P" 6

R_0. RB
T. , E,
She started
The condition started ago
investigations for
after .
delayed menarche
The condition is(__/not)
at the age of .
associated with symptoms
She has (__/not)
suggestive of in the form of
normal pubertal
o Pregnancy
changes in the
o Cryptomenorrhoea
o Increased ICT
form of . at the
o Psychological
age of . .
The condition is
disturbance
(__/not)
o Chest & heart
associated with
disorders
symptoms
o Prolactinoma
suggestive of :
o Excessive hair growth
o Cryptomenorr
& hoarseness
virilizing tumor
hoea in the
o DM polyuria ,
form of .
polyphagia , polydepsia
o Increased
o TB
ICT
o Hyper/Hypothyroidism
o Psychological
o Pregnancy
disturbance
o Menopause
or head
She sought
trauma
o Chest & heart
disorders.
She sought .
Medadteam.org
More than you dream
2011/2012
II)HISTORY OF PRESENT ILLNESS IN OBSTETRICS SHEETS

Complaint
Gestational age in months
Cause of admission
" :, I= # % &. E

= A $. I"#" A
_________________
She is a pregnant in ..m coming for ANC as she (is diabetic/ is
hypertensive/ is cardiac/ has previous CS/has history of recurrent
[miscarriage/ IUFD]/ has vaginal bleeding with pregnancy/ is Rh ve )
**********************
A) LMP, EDD and GA
Ask about 1st day of LMP

o Doesnt remember
Ask about her 1st U/S
When it was done and GA when it was done
The most accurate results are obtained if U/S was done

between 16-24 w
Ask about date of her pregnancy testsubtract then d to get 1st day
of LMP
o Remembers use Neagles formula to calculate EDD (based on the fact

that duration of pregnancy =280 d =40w 2w)
O add 7d then add 9 m(or subtract 3m if 4-12)
1 add 14d then 9 m
Single coitus( duration of pregnancy =38w=265d)rape- travelling

husband- IVF/ETsubtract 7d then add 9m
P". D % ,
P".& 6 9"D " 6
@ 6 $- : ," P".& 6Q % E, " 6
_________________
NB
Calculate days first then months to avoid miscalculation
1m=4w+2d
2m=8w+4d
3m=13w
__________________
Medadteam.org
More than you dream
2011/2012
She is pregnant w ..d as her 1st day of LMP was on ../../..and so her EDD is
../../.. provided that her last 3 cycles are regular occurring every 28 days
without use of hormones in last 3 months
*******************
B) Review of current pregnancy and warning symptoms

1. Pregnancy test (when/ blood or urine)
2. 1st trimester
o GITnausea and vomiting (VS HEG +hospitalization and weight loss)- cravingconstipation- heart burn)
o UT frequency of micturation (VS UTI +nocturnal frequency, dysuria and
midstream urine sample for culture)
o CVSpalpitations- dyspnea- postural hypotension- dizziness
o Breast tenderness and enlargement
o Cramps in lower abdomen radiating to the back
o Disorders
Vaginal bleeding abortion- V.mole- ectopic
Vaginal discharge infections
Fever, dysuria, loin pain Pyelonephritis
nd
3. 2 trimester
o Alleviation of 1st trimester symptoms
o Quickening (1st perception of fetal movements)
At 16-18w in MG and 18-20w in PG
Normally 10movements/10h
o Progressive abdominal enlargement( VS polyhydramnios+fetal movements)
o Disorders
Preeclampsia (LL edema- blurred vision- )
Placenta praevia (bleeding)
PROM (gush of fluid)
DM( polyphagia- polyuria- polydepsia)
HF( palpitation- dyspnea- LL edema)
Pyelonephritis (Fever, dysuria, loin pain)
rd
4. 3 trimester
o Lightening
o frequency of micturation
o fetal kick count, difficult walking, false labor pains and discharge
o Disorders as 2nd trimester
Medadteam.org
More than you dream

5. Warning signs
o Persistent
headache
o Blurred vision
o Excessive vomiting
o Epigastric and right
hypochondrial pain
o Diminished fetal
movements
o Vaginal bleeding
o Fluid per vagina
o LL edema
2011/2012
& . E" %

P". % ,9 % & 6 9"D " 6
V9A % ,=B 3 %
% L-Q D R % 6 $
( #"<6
?% VA p9' X(E 66! <Q"
[LE &'
" 6 ,9 % : % & p9' " 6Q D"
, L. & Q
P". _(& Q "< .
, % . Q"
"6Q & " #6 9D ,=B 3 D %
L" _ & <"
I<6 F-"< & 6"<. & ?
$R % 8 % &
, % . RA" 6"<. : % &
N9 $% _ %
% &
P@
D> (" % : &(_&
Q $. . I LE &
. A
_________________
First the patient noticed missed period so she made a pregnancy test in
(blood/urine) on../../.. and it was +ve
(She passed through a normal 1st trimester apart from mild nausea, vomiting
.which disappeared spontaneously by the end of 1st trimester/the patient
suffered from [HEG/UTI] in the form of ..and she was treated by ..)
She perceived fetal movements for the first time at ..w and since then she
counts movements /d
There was history of lightening and increased frequency of micturation in the
3rd trimester
(She has no history warning symptoms as ..., .., .. /ANC was normal till w ago
when she develops [and discuss what happens in details] but no other
symptoms as )
Medadteam.org
More than you dream
2011/2012
she attended regular ANC visits in Kasr el aini outpatient clinic where she
was admitted .. ago and investigations in the form of Rh, liver and kidney
function tests, blood and urine analysis and U/S were done and (show normal
results /no results available)treatment was given in the form of iron tablets
bid and system review reveals no other abnormality (in routine ANC sheet only)
*********************
C) Analysis of complaint
It involves analysis of complaint during and before current pregnancy,
possible cause or risk factors, complications and effects on both mother
and fetus, previous investigations and treatment and their results
This part is different in different sheets and not mentioned in routine ANC
sheet
D) Previous investigations and treatment and their results

See before
@3 0!+ O! 0(' #
~~~~~~~~~~~~~~
E) Admission
See before +mode and time of delivery
@ '!
~~~~~~~~~~~~~~~
F) System review
See before
1Q+ 892 .= % M .=
~~~~~~~~~~~~~~
Medadteam.org
More than you dream
2011/2012
1-DIABETES WITH PREGNANCY
1st known to be diabetic

o During pregnancy
This one
Previous one ttt between
pregnancies
o Before this pregnancy
Type1 in young age and on insulin
Type 2 in old age and on OHG
How she knew she was diabetic
o Symptoms of DM (polyuria- polyphagiapolydepsia- weight loss)
o Blood or urine glucose test
Complications
o Before pregnancy
CVS diabetic foot-HTN- CVD(by
echo)
CNS peripheral neuropathy
UT nephropathy (kidney function
test VS PE)
Eye retinopathy
o During pregnancy
Mother
Diabetic coma
PEHTN+ proteinuria + LL
edema
Infectionsmoniliasis(itchin
g)- UTI- soft tissue
infection
Fetus
IUGR, oligohydramnios IUFD
Macrosomia, polyhydramnios
Anomalies(VSD)
Investigations (blood glucose test-urine glucose
and acetone-U/S)
TTTDiet control
o OHG(drug- dose- time- result- shift to
insulin during pregnancy)
o Insulin (type[regularP3; NPH1Q ]dose- how many shots- when taken)
Medadteam.org
I " ." %

& 6 % & 6Q V. o
D" E"& 6Q $ F3 o

D"&6Q& 9: $.I o
: > $,<E
I " %
$. " 6Q" " 0 o
#" q_R <Q" >
< W" " " "
% I & Q " 6 o
" -"E " . ,9
$. (.& #. & '
I<
&#. F 0 RB 6 o
A %
R,? % &6" <Q" o
=% [ Zo 6 o
&#.
% $ : Q% 6 o
&#.
=99 I ,98 A &
,9 % >N!O & o
6"<. ?V.
-. % "=A & o
% VA ,9" : ,9
E,W V. A
Q $. L" % % & o
"= 6"= Q= E,
R. &
I. % "=- & o
E
& 6 $. 9& _
. X, FR &(_ & o
, %
" -"E" . E, 6 o
"-"E P". % I & Q 6
More than you dream
2011/2012
>&6T" X I< D"

IR. %? $,<E D" o
)I< N9T. & P". , % . D" " A
P".("= :"= A P".= ,E & 6Q& 9: : D" o
___________________
The patient knew for the first time that she had diabetes (ago/in previous
pregnancy/ during this pregnancy) when she developed (polyuria/ polydepsia
/polyphagia/ weight loss/ marked abdominal enlargement..) , she sought
medical advice at . Where blood glucose test was done and revealed
elevated blood glucose levels .
(She was advised to do diet control/ she was given ..insulin [..injections
/day ..{dosetiming}/she doesnt know the dose]/she was given OHG .[dosetiming]) and DM was (__/not) controlled.
and pregnancy was terminated at w by . And (since then she was on [ttt]
and DM was[__/not] controlled/ after pregnancy diabetes disappeared
completely)
The condition (wasnt associated with any complications as./was associated
with which appeared . Ago in the form of .but no other complications as
.
Diabetic control is carried through diet control (insulin therapy which was
given in doses before breakfast NPH and regular insulin and at
pmNPH and regular insulin and DM was (__/not) controlled as evident by
follow up of fasting and 2h postprandial blood glucose. Last estimation was ....
ago and revealed
~~~~~~~~~~~~~~~

Medadteam.org
More than you dream
2011/2012
2- HTN WITH PREGNANCY
Blood pressure when first discovered

o Before this pregnancy
Ttt taken
Controlled or not
Superimposed edema , proteinuria
and headache
Complications
Nephropathy renal
function
Hypertrophic cardiomyopathy
echo ECG
Cerebral stroke
Retinopathy
o During previous pregnancy
In between pregnancies
Normal no ttt
High on ttt
o With this pregnancy when noticed for
the first time
Before 20 w
After 20w
Warning signs
o Headache OCD- site- severity- character
o Severe vomiting and blurred vision
o Epigastric or right hypochondrial pain
o Edema of LL, fingers and face
+ proteinuria
Complications
o Maternal
Eclampsia convulsions
Renal problems renal function
o Fetal IUGR (U/S[ biophysical profileCTG]- fetal kick count- placental
insufficiency test)
Investigations CBC- urine analysis- kidney and
liver function test
tttnature dose- duration- controlled or not
Medadteam.org
N!O P".( #"

& 6Q % N! & o
X
& 6 % > o
E"& 6Q $ F3
& . N!
D"
. $. o
F3 D"
F3 ) N9".
N!& & 6Q
>$. " . A
$. (. ' & o
P I % & #. R N!
6 % _A F 0
$R % &#.
& <" 6Q N! 6
? o
&. $% EI. LP".
I<. D 6 &

: $R % 8 % & o
6"<.
$% $_9 %
% & o
N9
R,? A & o
6<A % I.
> % & , & Q 6 &
. X, Q" _(&9D
&. &(_ E, 6 , %

P I % &#. -# A &
& 6Q
,??,Q% & Q 6
9 P [ Zo , & Q
, % . D"
P".
: D N9T". N!&
" . N!
More than you dream
2011/2012
NB
Chronic HTN sustained of BP >140/90
Gestational HTN of BP >140/90 after 20w of pregnancy
Preeclampsia of BP >140/90 after 20w of pregnancy +proteinuria
>0.3gm/24h
The condition started.. ago when (the patient noticed/ BP was routinely
measured during ANC visit and was found to be high).she sought medical
advice at where(investigations/management)
She has (__/no)complications of elevated BP (as)
Her BP was last measured ..ago and was
~~~~~~~~~~~~~~~
3 PREVIOUS CS
Each CS
Order of pregnancy
Time
Place
Indication
Complication
Intraoperative
Anesthesia
Injury intestine, bladder
Need for blood transfusion
Postoperative
Wound infection
PPH
Puerperal sepsisfever, diffuse bilateral lower
abdominal pain, offensive vaginal discharge and
admission to fever hospital
DVT and pulmonary embolism
" . "= 6 &6 =E % E

$%
6R& #. & '&
=
. , A W" % &#.
& 0E "-"
6R R (. & '
- I. % ' "=o
&0E "-" B [LE A o
,I_ %
E,W A o
="Q % I LE
#
6Q( #"<. % L-Q o
=% A . A & o
_A
Z _ - & o
Z % &#. A
Her (1st /2nd /) CS was y ago in her ..pregnancy. it was carried out in
(hospital name) at the ..w of gestation because.. with (__/no) intra or post
operative complications (as..for which she took..)
Medadteam.org
More than you dream
2011/2012
4-ANTEPARTUM HEMORRHAGE
Onset
o Spontaneous
o Following trauma
o Following PV examination or intercourse
Course
o Continuous/intermittent
o Single attack/ recurrent
Duration
Amount
o Spotting
o Excessive presence of clots- No of
pads- need for blood transfusion
Color (Bright red- Dark red)
Other symptoms
o Pain
OCD
Site
Radiation
Character
Severity
Precipitating factors
o PE
See warning symptoms of
pregnancy
Quality of fetal movements after
the attack
Speculum examination
_ 9D R @ , [ L
6A
V_0". 6"<. [L&
I" . &'D & o
0 [L
" 6
, % 3,% "! o
9I V " % o
& 0E "-" & o
E,
[L V.
% &
@R >[ L V. & >
o
&0 L 0 o
$% V6< N9 $% >
o
& .
> o
0" @ L" A % o
& ?
& . $% EI. LP".
I<. D 6 &
: $R % 8 % & o
6"<.
N9 $% $_9 %
% & o
I. R,? A & o
6<A %
Q "< [L R o
. & :_(& >
, %
9=. T6 Q% 6R&
Bleeding started .ago. it was (spontaneous/ proceeded by..), it was

(continuous/intermittent)(single/recurrent) attacksin amount as she
changes .pads/d([__/no] blood clots)blood was .in color ,it is
(painless/associated with [character]pain of onset .ago in
[site]radiating to. And precipitated by)
It was(__/not) associated with symptoms of PE (as.)
She felt fetal movements after the attack with average.movement/d
Medadteam.org
More than you dream
2011/2012
5- HABITUAL ABORTION AND IUFD

-No of previous abortions
-Each abortion
Date
Duration of pregnancy or
Pattern
Preceded by ROM- pain- vaginal bleeding
Associated withpain- bleeding
Mode
o Spontaneous/induced
o Short/long duration
o Followed by evacuation/ curettage
o Place
OutcomeIUFD-neonatal death
Post-abortive complicationsbleeding- sepsis
IF IUFD ask about suppression of lactation
-Possible cause
Histological examination of products of
conception
Anomalies in products of conception
Advanced medical problem
o DMpolyuria- polyphagiapolydepsia
o HTN-heart disease- kidney disease
o Thyroid changesrecent change in
weight- intolerance to heat or cold
Uterine anomalies or fibroids HSG-U/S
Infections ToRCH, VDRL
Auto immune disordersDoppler studies
o Aspocid +klexan or steroids
Isthmic incompetencecerclage operation
LPD hormonal profile/hormonal therapy
Bleeding from different orifices
& 9: . _ 0
". E> >N0<
& 6 R &'
&. E %
= 9: 6 $ L" &6Q . &
&0"
'& Q N0<
9: L" @. % &
N0<& 9: < \)Q" &
B
[ LE @R. P09 N0< &
: D < L &
, ," @> , L & o
$% LE
N0< R Q[ T 6 o
LE 6 . . LE &(_ &
N0< R % I LE &
N0< R ?% $9 % &
E -<E & Q , 6 N0< R &
=A>
,# , % N0< &
F : I N!O &
[Zo & Q,I, E,. & Q 6 &
("% "T > & : 8 P
,- 6" E % ! D>
! 9' RB E, 6

FE>
?& _(& Q% 6
&6Q
Q $0 ( 3 $9 D" o
L, -
%L & Q 6
& 9:
D N 6 6
Her (1st /2nd /)abortion was y ago at w pregnancy. It was preceded by .. and she.
It was terminated (spontaneously/by..)at(..place..). it was(__/not)followed
by(SE/curettage)with (__/no)post-abortive complications(as.)
The products of conception shows (__/no)congenital anomalies and histopathological
studies were(__/not)done and (___/revealed../ no reports available).
She has (__/no)general medical disease as DM,HTN,.
Medadteam.org
More than you dream
2011/2012
6 HEART DISEASE WITH PREGNANCY
Onset congenital- before pregnancyafter pregnancy

Causecongenital rheumatic(recent
rheumatic activationdifficult swallowing)hypertensive- ischemic
Symptoms
o Pulmonary congestive symptoms
Dyspnea
Cough
Hemoptysis
Expectorationamount- colorodor- consistency
Orthopnea
Nocturnal dyspnea
o Systemic congestive symptoms
Dyspepsia
Chest and right hypochondrial
pain
Yellowish discoloration of
sclera
Ascites, LL edema
Palpitations
o Low cardiac output
Headache , dizziness and lack
of concentration
Easy fatigability
Blurred vision
Intermittent claudications
" % R. F 0 .

P". F 0
99
0 D F , & o
E .L. P6 A o
A& 6Q -?! &
V 9 % ,R?
N! F9< o
,': ? Q A & o
A" $# %
- &
E, = !
% Q(< E B o
Q" 6
." 6 L" X( B &
W. P ."
L(. , $. .,0" &
X(E B P
% ,R? % 9R" & & >o
=
$_9 ' %
% &
& . $% V6< $%
0 @ L" A %
& 9: ?(
. A 0<" A
6T". 9 : < Q"
_9W .
L D< ' Q" & o
,=-. &: V. 9R""
% 8 %
NB Diagnosis should include
Etiologycongenital- rheumatic- hypertensive- ischemic

Anatomy which valve
Functionalstenosis- incompetence
Complications subacute bacterial endocarditis
Cardiac capacity grade I II III IV
~~~~~~~~~~~~~~~
Medadteam.org
More than you dream
2011/2012
7- RH INCOMPATIBILITY
When she knew she is Rh ve

o During pregnancy
o In between pregnancies
how she knew
o Intake of Rh antibodies
o History of neonatal jaundice
o History of admission to neonatal unit
o History of phototherapy or exchange
transfusion
o History of neonatal death or IUFD
o Hydrops baby
Current pregnancy
o Anti-RH antibody titre
o U/S
o Need for amniocentesis
o Need for intrauterine transfusion
F q P"." %

E"& 6 $ & 6Q
, &6 R q > 0 D&
>N0
, % ?(A >, $. &
>, R
" $<"96<
: &D "
& 0E Z,O
> (", R . (3> $. &
&
D . ' :
% . % . , >> $. &
q . <A & Q " 6R=_
"-"E
-" E, " 6
D $A"Q.
=E ,: &
_(& ! $, & Z< $.
&
D_(&
~~~~~~~~~~~~~~~
ORAL
QUESTIONS
for answers revise the topics mentioned in introduction
What are the investigations you are going to ask the patient to confirm your
diagnosis?
How are you going to manage your case?
What are the complications of this disease?
What are the possible (risk factors/etiological factors /predisposing
factors) of this condition?
What are other symptoms and signs of this condition?
Why you asked the patient about?
Medadteam.org
More than you dream
2011/2012
Provisional diagnosis
1.
2.
3.
4.
Name
Age
Gravidity and parity
GA (only in obstetric sheets)
Gynecology
(..Name.. )is y old ,GP
with.living children males
females[nulligravida1ry
infertility],with(according to
complaint),with (__/no
[general medical
disorder.]of[..duration..]on[..
ttt..]) .])(___/previous
.operation) (for further
investigations/foroperation)
Obstetric
Prolaps
e
Bleedin
g
Disorder, cause and complications

Associated medical condition
Previous operations
Plan of management
genital prolapse most probably (Cystocele ,

Rectocele or cystorectocele ) with (no
complications and PFs ) ,with (no) previous
attempts of surgical repair
(Menorrhagia / metrorrhagia /
menometrorrhagia / contact bleeding /
polymenorrhoea) of years duration most
probably .. with (no) previous curettage
menopausal for with postmenopausal bleeding
for . most probably ..
Post
menopa
usal
bleedin
g
Infertil With infertility most probably due to factor
ity
Fistula with urinary incontinence , genitourinary fistula
recurrent /not ([Vesico/Uretro]vaginal
fistula) due to with (no) complications
Pelvipelvi-abdominal swelling of duration most
abdomi probably with (no) complications
nal
mass
Amenor With (1ry/2ry ) amenorrhea most probably
rhea
ofcause
ANC
DM
HTN
Medadteam.org
5.
6.
7.
8.
Coming for ANC

DM (type1/2/gestational),last blood glucose
is..,(controlled/not),(complications if
present),on(..ttt..)
(PE/gestational HTN/chronic HTN/PE
superimposed on chronic HTN),last BP is and
albumin is.,(controlled/not)with(complications
if present),on (..ttt..)
More than you dream

(..Name.. )is y old ,GP
with.living children males
females pregnant w
(GA is mentioned in even
numbers) ],with(according
to complaint),
(__/[PE/APH/HD/DM/
HTN/twins.for{..duration..
}..)treated
by.])(___/previous
.operation) (for further
investigations/foroperatio
n)
Previous
CS
APH
Habitual
abortion
CVD
Rh
incompati
bility
2011/2012
Previous CS for (..indication..)

APH most probably (placenta
praevia/accidental hge)
Habitual abortion ..times most probably due
to.
CVD(rheumatic/congenital/ischemic/hypertensi
ve)(..valve..)(stenosis/incompetence)with(compli
cations if
present)class(I/II/III/IV)functional capacity
of heart, on (..ttt..)
Coming for ANC as she is RH-ve pregnant (
with history of ..complication..)
List of abbreviations
ANC Antenatal care
APH Antepartum
hemorrhage
BP Blood pressure
CVD Cardiovascular
disease
Cx
Cervix
d
Days
EDD Expected date of
delivery
GA Gestational age
Hb Hemoglobin
HEG Hyper emesis
gravidarum
HF Heart failure
Hge Hemorrhage
HSG Hystero salpingo
graphy
Medadteam.org
HTN
LL
Hypertension
Lower limb
$
Rt
LMP
LPD
Last menstrual period

Luteal phase defect
SD
SE
M
No
OCD
Month
Number
Onset-course-duration
OHG
PE
PEB
Oral hypoglycemic
Preeclampsia
Premenstrual
endometrial biopsy
PF
Predisposing factors
PPH
Post partum
hemorrhage
PROM Premature rapture of
membranes
Syndrome
Right
Subdermal
Surgical
evacuation
ttt Treatment
U/S Ultrasound
UT Urinary tract
VD Vaginal delivery
VS Versus
VSD Ventricular septal
defect
w
Weeks
Wt Weight
y
Years
More than you dream

Medad How To Write An OBGYN Sheet

Загружено:

Сведения о документе

Оригинальное название

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Medad How To Write An OBGYN Sheet

Загружено:

Авторское право:

Доступные форматы

How To Take An OB/GYN Sheet?

II)HISTORY OF PRESENT ILLNESS IN OBSTETRICS SHEETS .............. 34

Provisional diagnosis ............................................................... 46

More than you dream

How To Take An OB/GYN Sheet?

Before you begin

More than you dream

How To Take An OB/GYN Sheet?

Gravidity and parity

More than you dream

How To Take An OB/GYN Sheet?

Why you asked about:

More than you dream

How To Take An OB/GYN Sheet?

2-Complaint and history of present illness

More than you dream

How To Take An OB/GYN Sheet?

Diseases (DM, HTN,

Drug intake and drug

& 9:  A   I#6

More than you dream

How To Take An OB/GYN Sheet?

She has history of (radio/ hormonal) therapy .years ago to treat.

Why you asked about:

Diseases (DM, HTN, CVD)

  I#6 X(E @  R % 

More than you dream

How To Take An OB/GYN Sheet?

There is family history of as her (..mother) also had ..

If menopausal +she is menopausal for .y

More than you dream

How To Take An OB/GYN Sheet?

What is normal and abnormal:

Within 1w before or after expected

Continuous dull aching

More than you dream

How To Take An OB/GYN Sheet?

What is the menstrual index?

Full term Pre term Abortion Living

Outcome Puerperium lactation

More than you dream

How To Take An OB/GYN Sheet?

More than you dream

How To Take An OB/GYN Sheet?

The outcome is (living [male/female]/ IUFD /stillbirth), and puerperium was

When started and when stopped

Why stopped (seeking fertility/complications)

& 6Q V6   " .W"

&6Q V. ,9 IUD

NB/ F, Tubal

 T"E &'Q & ,9 > % 6- .

More than you dream

How To Take An OB/GYN Sheet?

What is the most suitable frequency of intercourse for a couple desiring

More than you dream

How To Take An OB/GYN Sheet?

Complaint and history of present illness

More than you dream

How To Take An OB/GYN Sheet?

I)HISTORY OF PRESENT ILLNESS IN GYNECOLOGY SHEETS

B) Analysis of the associated gynecological symptoms

Course usually gradual

Duration if <2days hypomenorrhoea & if >6 days

& 9: A I#6

I#6 X(E @ R %

& 6Q V6 " .W"

&6Q V. ,9 IUD

NB/ F, Tubal

T"E &'Q & ,9> % 6- .

T". & 0

P". $. < \

( P". PL-Q ) P". PR' 0 P"A

I N!O E A $. I"#"

Regular vaginal bleeding R. P% [LE P -

": & . [L

& 9: P" 0E D"

R_: . R P

"! 9I . " P%