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Obg Case Presentation

This document presents a case study of an obstetric patient. It includes the student's profile, patient demographic data, medical history, assessment using Gordon's Functional Health Patterns, physical examination findings, and obstetric assessment. The case study documents the patient's care over time and assessments. It collects relevant information to understand the patient's condition, health patterns, physical status, and progression.

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namitha
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42K views12 pages

Obg Case Presentation

This document presents a case study of an obstetric patient. It includes the student's profile, patient demographic data, medical history, assessment using Gordon's Functional Health Patterns, physical examination findings, and obstetric assessment. The case study documents the patient's care over time and assessments. It collects relevant information to understand the patient's condition, health patterns, physical status, and progression.

Uploaded by

namitha
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Introduction - Demographics: Captures demographic data of the patient and outlines the patient profile, including admission details.
  • Student's Profile: Provides fields for recording student and patient information such as name, clinical area, and unit.
  • History Taking: Includes sections such as general history, marital history, and a layout for family medical history.
  • Gordon's Functional Health Pattern Assessment: Outlines the eleven functional health patterns to assess patient's health management and lifestyle.
  • Physical Examination: Details procedures for physical examination including vital signs and systemic reviews.
  • Focal Assessment: Describes the obstetric assessment procedures including inspection and palpation techniques.
  • Diagnostic Test: Provides a template for documenting diagnostic test results and interpretations.

OBSTETRIC CASE PRESENTATION/STUDY

STUDENTS PROFILE:

Name-

Classes-

Clinical area-

Specific unit-

Duration of posting-

Duration of care-

INTRODUCTION:

DEMOGRAPHICAL DATA OF THE PATIENT

PATIENT PROFILE-

Name-

Age/sex-

Ward-

Bed no-

Date of admission-

Education-

Religion-

Religion-

Occupation-

Marital status-

DIAGNOSIS-

Date of care started-


Date of care ended

HISTORY TAKING
GENERAL HISTORY

MARITAL HISTORY

FAMILY HISTORY:

[Link] Name of the Age/se Relationship Education Occupation Health


. family member x condition
FAMILY TREE:

SOCIOECONOMIC HISTORY:

MENSTRUAL HISTORY

OBSTETRIC HISTORY

HISTORY OF PRESENT PREGNANCY


GORDONS FUNCTIONAL HEALTH PATTERN ASSESSMENT:

1. Health perception-health management pattern-

2. Nutrition-metabolic health pattern-

3. Elimination pattern-

4. Activity exercise pattern-

5. Sleep rest pattern-

6. Cognitive perceptual pattern-

7. Self perception pattern-


8. Role relationship pattern-

9. Sexuality reproductive pattern-

10. Coping stress tolerance pattern-

11. Value belief pattern

OPD /CASUALITY NOTES

WARD NOTES

PHYSICAL EXAMINATION:

1. GENERAL EXAMINATION-

General appearance-
Orientation-

Speech-

Body movements

Nourishment-

Height-

Weight-

2. VITAL SIGNS-

Temperature-

Pulse-

Respiration-

Blood pressure-

3. INTEGUMENTARY SYSTEM-

Colour-

Texture-

Turger-

Lesions and other signs-

4. NAILS-

Colour-

Capillary refill-

Other symptoms-

5. HEAD AND NECK-

Shape
Size-

Dandruff-

Hair-

Range of motion-

Lymph nodes-

Other symptoms-

6. EYES-

Symmetry-

Conjunctiva-

Cornea-

Pupils-

Vision-

Other symptoms-

7. EARS-

Position-

External ear-

Hearing-

Other symptoms-

8. MOUTH-

Symmetry-

Lips-

Teeth-

Tongue-

Appetite-
Other symptoms-

9. ABDOMEN-

Inspection-

Palpation-

Percussion-

Auscultation-

Other symptoms-

10. EXTREMITIES-

UPPER EXTREMITIES

Symmetry-

Range of motion-

Edema-

Pain-

Other symptoms-

LOWER EXTREMITIES

Symmetry-

Range of motion-

Edema-

Pain-

Other symptoms-

11. RECTUM AND GENITALS-

Skin colour-

Bowel habits-
Bladder movement-

Other symptoms-
FOCAL ASSESSMENT

OBSTETRICAL ASSESSMENT

INSPECTION: -

PALPATION: -

Fundal grip;

Lateral grip;

Pawlick grip;

Pelvic grip;

AUSCULTATION

PER VAGINAL EXAMINATION;


DIAGNOSTIC TEST:

Date Name of investigations Patient value Normal value Remarks

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