Clinical Sheets
Clinical Sheets
Clinical Sheets
gravidity and parity, occupation, residence, special habits, husband data (in infertility sheet)
2) Complaint:
3) Present history:
4) Menstrual history:
Menarche , Rhythm,
Duration/ Frequency (menstrual index)
Amount of menstrual blood (change how many pads per day)
Dysmenorrhea, PMS
Intermenstrual pain bleeding, discharge
NB: L.M.P (unacceptable to forget it, in some sheets as bleeding, infertility, obstetric sheet…. it
needs to start within the present history even)
5) Obstetric history:
4-Digit Code: F P A L
Contraception:
6) Past history:
Past Medical disorders e.g. HTN, DM, BA, TB, RHD, RF, bilharziasis.
Past Surgical
Allergy
7) Family history:
Similar condition
Medical disorders e.g. HTN, DM
Twins
8) Provisional Diagnosis:
Name, Age, Gravidity and parity, Complain and its duration in medical terms,
Most probable DD, relevant medical problems, relevant surgical procedures done
II. Obstetric sheet
1) Personal history : (NAM PORSH)
- Name - Age - Marital state
(don’t say G4 P3 )
2) Complaint:
She is pregnant in the …. Month and coming for antenatal care due to …..
3) Present history:
She is pregnant …. Weeks as calculated from the 1st day of her L.M.P. which was on…..
Review of the 1st trimester:
nausea
vomiting
bleeding
Review of the 2nd trimester:
perception of fetal movement (quickening)
relieve of first trimesteric symptoms
Review of the 3rd trimester: Warning symptoms :
headache , blurring of vision, vomiting
epigastric pain, Rt hypochondrial pain
number of fetal movement
vaginal bleeding , gush of fluid
LL oedema
Analysis of the complaint
Analysis of investigations and treatment
Review of other system
2)Complaint: Excessive or Irregular or Excessive irregular vaginal bleeding for how long
3) Present history:
Analysis of the complaint:(menorrhagia, metrorrhagia, menometrorrhagia)
onset, course ,duration , amount of bleeding (number of pads, clots)
Analysis of other related gynecological complaints :
pain (type,site,radiation,severity,…..)
mass (onset, course, duration,site,..)
discharge (amount, colour, odour ,itching)
Analysis of the causes :
preceding event e.g. period of amenorrhea, I.U.D. insertion, injectables
contact bleeding
bleeding from other body orifices, ecchymosis
thyroid disorders
heart disease (dyspnea ,palpitation ,L.L.O. ,….)
hypertension
Analysis of the Consequences: anemia ( dyspnea, easy fatigability, blurring of vision)
Analysis of investigations and treatment : U/S, D&C, CBC, coagulation profile
Review of other systems.
3) Present history:
Duration of menopause
Symptoms suggestive of distant metastasis:
Lung (cough , hemoptysis,..) Liver ( rt hypochondrial pain , jaundice )
Bone ( aches and pathological fractures ) Brain ( projectile vomiting ,
headache,…)
G.I.T. symptoms ( vomiting , constipation , bleeding per rectum)
IV.Genital prolapse sheet
1)Personal history: as general sheet
2)Complaint: mass protruding from the vulva , sense of heaviness + duration
3)Present history:
5) in Obstetric history: It is important to ask whether her deliveries were difficult and prolonged
ended with use of forceps of ventouse ,delivery of macrosomic baby
V. Infertility sheet
1) Personal history As general sheet plus
ask about previous marriage
children from previous marriage
the age of the youngest child
husband personal history: age/ occupation/ smoking/ another marriage and the age
of the youngest child from the other marriage.
2) Complaint : Failure of conception for …….. years despite of regular marital life
3) Present history:
Duration of her current marriage:
Analysis of the causes:
Male factor of infertility:
o semen analysis ( results, time) - treatment (nature, duration, result)
o previous operations (hernia, varicocele) - medical disorders and drugs.
Ovarian factor:
o symptoms suggestive of ovulation (regular cycles ,spasmodic dysmenorrhea,
premenstrual mastalgia, intermenstrual bleeding ,pain and discharge)
o hirsuitism , oligomenorrhea ,hypomenorrhea (P.C.O.)
o symptoms suggestive of ovarian failure (hot flushes , nervousness , bony aches)
Tubal factor:
o symptoms suggestive of salpingitis ( bilateral lower abdominal pain associated
with offensive vaginal discharge, fever and chills)
o previous abdominal operations that may lead to adhesions
Uterine factor :
o previous dilatation and curettage followed by decrease in the amount of menstrual
flow ( suggestive Asherman syndrome)
Cervical factor: vaginal discharge + backache, erosion, cautery, cervical amputation
Sexual factor: Fequency per week, Dyspareunia ( superficial or deep ), vaginismus,
effluvium seminis
Analysis of investigations and treatment :
Investigations as: hormonal profile, hystrosalpingography , sonohystrography,
premenstrual endometrial biopsy, folliculometry, laparoscopy ( mention the results )
Induction of ovulation : tablets, injections, how long,
History of Tuboplasty
Previous ART (IUI, ICSI)
Review of other systems: General or Endocrine as thyroid dysfunction, DM, TB,
Hyperprolactenemia
4) 5) 6) 7) 8) Menstrual, Obstetric, Past, Family histories and Diagnosis: as General Sheet.
VI. Primary Amenorrhea sheet
1)Personal history: As general sheet
2)Complaint: Non occurrence of menstruation Or Absence of menstruation
3) Present history:
3)Present history:
Exclusion of pregnancy:
pregnancy symptoms (nausea, vomiting, abdominal enlargement)
pregnancy test
Pituitary cause:
galactorrhea
symptoms suggestive of pituitary adenoma ( increased I.C.T. ,
visual field changes)
Ovarian cause :
hirsuitism , deepening of voice , pelvi-abdominal mass
hot flushes , nervousness, bony aches
Uterine cause:
Symptoms suggestive of T.B.
history of D&C (overcurettage suggestive of Asherman syndrome)
General cause:
As 1ry amenorrhea
N.B. menstrual history taken about menstrual condition before amenorrhea