The Patient Medical File

Patient’s Medical File

I. General information about the patient and
DIAGNOSIS
II. Consent – hospitalization, tests, interventions
III. Medical data
– anamnesis & clinical exam - OB-GYN
– Lab tests
– Pathology
– Other (sonography, IRM, CT, RX…)
IV. Interventions/O.R. protocols
V. Anesthesiology file
VI. Progress notes/physician orders
VII. Medication
VIII.Vital signs
 General information

• Age - DOB
• Marital status/children
• Domicile

• Profession

• Social/Economical conditions

• Habits (tobacco/alcohol, diet, exercise, sexual

orientation)

• Medications
 Gynecological history

• Menarche
• Menstrual cycles (regular/monthly, lenght,
duration, blood flow)
• Menopause (from when)/ HRT
• Infertility (etiology, treatment)
• Contraception
• Last PAP smear/HPV
• Breast check-ups (mammogram)
• Sexually active?
 Obstetrical History
• Abortions
– Spontaneous
– Missed abortions
– Elective
– Therapeutic/Medical
• Previous pregnancies: evolution, complications,
labour
– Type of delivery
– Weeks of pregnancy
– Birth weight/sex/APGAR score
– Pregnancy complicated by DM, high blood pressure
etc.
 Personal Medical History

• Hypertension
• DM
• Allergies
• Other (treatments/sequelae)
• Immunizations
• Cancer
• Chronic lung disease
• Kidney disease
• Liver disease
 Personal Surgical History

• Trauma of the pelvis

• Spinal surgery
• Abdominal surgery (apendicectomy)
• Gynecologycal surgery
• Transfusion ?
 Family history

Most important : mother, father, siblings

• Hereditary diseases (hemophilia, epilepsy)

• Arterial Hypertension
• Diabetes
• Coronary disease
• Obesity
• Malformations
• Neoplasms (ovary, breast, colon)
 Chief Complaint

A. Uterine contractions
 Rhythm
 Regularity
 Intensity
 Pain

B. Leaks
 Amniotic fluid (specify for how long, color +/-
fever, uterine contractions)
 Blood
 Mucus plug
 Chief Complaint

C. Other signs
 Fever
 Abdominal pain
 Lumbar/lower extremities pain
 Urinary symptoms
 Headache
 Nausea
 History of the present pregnancy
a) Date of last menstrual period LMP
b) Pregnancy follow-ups
 Number of check-ups
 Lab tests
 Vaccinations
 Ultrasound
c) Associated pathology to current
pregnancy
d) Treatments during pregnancy
 Pregnant Woman Examination

1. Introduction
– Wash hands, Introduce self, ask Patients
name DOB and what they like to be called,
Explain examination and get consent
– Expose patent’s abdomen, lying at 15
degrees
 Pregnant Woman Examination

2. General Inspection
– General: stable, comfortable,
breathlessness, pallor
– Pulse rate
– Head and neck: chloasma, anemia/jaundice
in eyes, nasal congestion, facial oedema
– Legs and Feet: swelling, oedema and
varicose veins
 Pregnant Woman Examination

3. Abdominal Inspection
– Distension
– Fetal movements
– Scars (c-section, laparoscopy)
– Skin changes
• Linea nigra
• Srtiae gravidarum (purplish sriae)
• Striae albicans
• Excoriations (cholestasis)
• Distended superficial veins
• Umbilicus eversion
– Cough for hernias
 Pregnant Woman Examination

4. Abdominal Palpation (Leopold exam)

– Fundal height
– Lie (orientation;
cephalic/breech/transverse/oblique)
– Presentation
– Liquour volume
 Pregnant Woman Examination

5. Auscultation of fetal HR
– >24 weeks gestation
– FHR auscultation
• Cephalic - halfway between the umbilicus and
ASIS
• Transverse – paraumbilical
• Breech – halfway between umbilicus and the ribs
– Feel mothers pulse at the same time
– Normal fetal heart rate 110-160bpm
 Perineum Examination
1. Visual external inspection

Inspection of the
soft tissue of the
lower and
upper genital
tract + urethra,
bladder, rectum
– Sometimes bony
pelvis
 Perineum Examination
2. Speculum exam

• Speculum exam:
– Vaginal mucosa, introitus,
cervix
– Evaluate leucorrhea,
bloody discharge
– Swab Tests (BV, STI)
– Cervical PAP smear
Perineum Examination
 Can you name the main anamnestic
components from the patients medical file?