Obstetrics & Gynaecology Clinical Case Proforma

For Ward Presentation — Department of Obstetrics & Gynaecology

| Date:

1. Identification & Presenter Details

Patient Name

Age / Sex

IPD / Bed No.

Occupation

Address

Date of Admission

Presenting Student & Roll No.

History given by

Patient Attendant

2. Chief Complaints

Tick all that apply (patients often present with more than one). Fill site, side and duration for each selected.

✓	Chief Complaint	Side	Site	Duration (since)
	Amenorrhea / missed periods
	Abnormal vaginal bleeding
	Abdominal / pelvic pain
	Vaginal discharge
	Infertility
	Pregnancy-related complaint (nausea/bleeding/decreased fetal movements)
	Menstrual irregularity
	Abdominal / pelvic mass
	Urinary symptoms
	Genital itching / burning
	Other:

3. History of Present Illness

Mode of Onset

Acute onset Gradual / insidious onset Related to current pregnancy Cyclical (menstrual-related) Post-coital / post-menopausal Other:

Character of Pain / Key Symptom — SOCRATES

To be filled whenever pain is a chief complaint (abdominal/pelvic pain).

S — Site
O — Onset
C — Character
R — Radiation
A — Associated symptoms
T — Timing
E — Exacerbating / relieving factors
S — Severity (0–10)

4. Menstrual, Obstetric, Marital & Contraceptive History

A. Menstrual History

Age at menarche

Cycle length

Duration of flow

Amount of flow

LMP (Last Menstrual Period)

EDD (if pregnant)

B. Obstetric History

Gravida

Para

Living

Abortion

C. Marital & Contraceptive History

Age at marriage

Duration of marriage

Contraceptive method used

Non-consanguineous marriage Consanguineous marriage Other:

5. Past, Personal, Family & Treatment History

6. General Physical Examination

Build

Nutrition

Consciousness

Vitals

PR (/min)

BP (mmHg)

RR (/min)

Temp

SpO2 (%)

RBS

GCS

6. Abdominal & Pelvic Examination

A. Abdominal Examination (Obstetric, if applicable)

Fundal height
Lie / Presentation
Fetal heart sounds
Uterine contractions

B. Abdominal Examination (Gynaecological, if applicable)

Inspection
Palpation

C. Per Speculum Examination

D. Per Vaginal / Bimanual Examination

7. Systemic Examination

9. Investigations

✓	Investigation	Findings
	Urine pregnancy test
	Ultrasound — pelvis / obstetric
	Hb / blood count
	Blood group & Rh typing
	Blood sugar (F/PP)
	VDRL / HIV / HBsAg
	Pap smear
	Hormonal profile (if indicated)
	Doppler study (if indicated)
	Other:

10. Diagnosis

Provisional Diagnosis

Differential Diagnosis

11. Treatment Plan

Conservative / expectant management Medical management Operative management planned Antenatal care plan Iron / folic acid / calcium supplementation Counselling given Follow-up plan

12. Summary

Auto-generated from ticks & entries above, in the fixed order of the sections — edit freely before presenting.

Presenting Student's Signature

Countersigned by Faculty / Resident

Obstetrics & Gynaecology Clinical Case Proforma — for teaching purpose · not a legal medical record

Sign	Absent	Present	Details (site / grade)
Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Edema

System	Normal	Abnormal	Details
Cardiovascular System
Respiratory System
Breast examination