1. My patient, Madam _________, a ___ y/o lady, G___P___ currently at ___w POA with a known case of ____________ is admitted for ___________ a/w __________ 2. Her LMP was on __________. EDD is on ____________. REDD _____________.
Antenatal History 1. This is a un/planned & un/wanted pregnancy. 2. Her urine pregnancy test (UPT) was tested positive at ____w POA. 3. Dating scan was done at ____w POA at _________________________________. 4. The early part of the pregnancy was a/w excessive vomiting but did not require any admission/medication. 5. Initial booking was done at ____w POA at ________________________________. (a) Her weight at that time was ____kg, height ____cm, BMI ____________. (b) Her BP was ___/___mmHg, Hb ____g/dL, blood group ____, Rhesus +/- (c) Urine test normal/showed proteinuria/glycosuria. (d) Hep B/HIV/VDRL screening was not/reactive for __________________. (e) MGTT was not/done ____ times because ______________, was normal/showed signs of hyper/hypoglycemia. Result __________________________________ (f) This was followed by BSP ( ____/____/____/____) taken at ____weeks. 6. Since then, she had a total of _____ follow-ups once per month, ____w POA onwards ____ times per month. All were uneventful. 7. Her latest scan was done at ____w POA at ________ showing parameters equal to date, single/multiple fetus, fetal presentation cephalic/breech, longitudinal/ tranverse/oblique lie, placenta at __________, amniotic fluid index (AFI) ________, estimated fetal weight ______kg. 8. The pregnancy has progressed well. She gained weight ______kg, in/appropriate. 9. She had several ultrasounds performed & was told the baby was growing well. Up till today, fetal movements were good & there were no signs of labour.
Past Obstetrics History Year Age SVD/LSCS boy/girl ______kg POA/full term alive & well
She had delivered _____ children, ____ boys ____ girls. All of them were delivered via FTSVD/except for ____ th child which was delivered by LSCS due to ____________. The post operative period was uneventful. The babies weighed between _____ to _____kg. All children are normal, alive & well.
If miscarriage: She had a history of miscarriage in ____ th pregnancy at _____w POA, confirmed by ultrasound. An Evacuation of Retained Products of Conception (ERPOC) was performed & there was no complication following the procedure.
If intrauterine death (IUD): She had a history of IUD in ___ th pregnancy at ___ w POA. There was no precipitating factor & it was diagnosed following a complaint of decreased fetal movements. The delivery was induced & a baby boy/girl was delivered vaginally. The baby was macerated but there was no abnormality detected. The placenta had gross infarction.
Past Gynae History 1. She attained menarche at _____ y/o. 2. Since then her menses had been ir/regular with ________ days cycle with normal/minimal flow for _____ to _____ days. 3. No/dysmenorrhea requiring medication/slight dysmenorrheal not requiring any medication or MC. 4. No history of intermenstrual, post-coital bleeding, menorrhagia, dyspareunia. 5. No history of UTI/STD. 6. Pap smear has never/done on ____________ showing ____________________________. 7. She uses contraception _______________________________ from ________ to _______. 8. She denies using any contraceptive methods. 9. For subfertility, sexually active? marriage how long? long-distance?
Medical History No history of DM, HT, asthma, renal disease, drug allergy. She is a known diabetic diagnosed since ________. The patient is on _______________________ medications/vitamins (if any). Diabetes is not/well-controlled. No complications secondary to the disease.
Surgical History There is no significant surgical history. She is a known case of thyrotoxicosis & had undergone thyroidectomy in ______ at ______. She is now euthyroid & does not require any medication. Appendicectomy?
Family History There is no family history of DM, HT, malignancy/cancer, congenital malformations, twins. She has strong family history of ________________________. Both her parents & one of her siblings are ____________ & on treatment. Dad ____ y/o ________________________ Mom ____ y/o _______________________
Social History She is a ____________ married to a _______________ in _________, ______ years. Their total income is RM _________. The live at the ____ th floor of _________________________________________ with/no lift. She claims not to smoke/drink/drug. Husband smoke/drink/drug. She wishes to have _______ children. / She claims her family is complete. Currently, her children were taken care by ____________.
Summary of History My patient is a _____ y/o lady G__P__ working as a _________, a known case of _________, currently at ____w POA, admitted for ______________________ a/w __________________ and awaiting delivery.
Postpartum History 1. My patient, Madam _________, a ___ y/o lady, G_P_ with a known case of _______ _____________ is admitted for ___________ a/w _________________, is currently at ____ day/hour post SVD/LSCS at ____w POA. 2. She was admitted at ____w POA in latent/active phase of labour with intermittent lower abdominal pain with mild/moderate/strong contractions ____ times in 10 min, a/w leaking liquor. 3. Upon admission, vaginal examination shows cervix is dilated _____cm. 4. Induction of labour (IOL) was done (if applicable) & she progressed to active phase of labour after ____ hours. 5. She was sent to labour room at _____am/pm & was augmented for ____ hours with pitocin. 6. Vaginal exam & artificial rupture of membrane (ARM) (if applicable) was done, which shows that the cervix is dilated _____cm & there was clear/meconium- stained liquor. 7. She delivered vaginally after ____ hours of active phase. 8. She delivered a baby girl/boy weighing _____kg with Apgar score of ____ at 1 min & ____ at 5 min. 9. Estimated blood loss was ____mL, Hb level decreased from ____ to ____g/dL. 10. The placenta was delivered by controlled cord traction, weighed _____g, complete, with blood & the cord pH is _______________. 11. No intra/postpartum complication noted. 12. Today, the patient is well & alert. On examination, she is not pale. 13. Vital signs are stable with BP ___/___mmHg, pulse rate _____ bpm, temperature ____C, not febrile. 14. Abdomen is soft & non-tender. 15. Uterus is firm & well-contracted at 18/20 weeks in size. 16. Lochia is normal with ____ half/fully-soaked pad/day, no active PV bleeding. 17. Patient ambulates well, had passed urine & defecated. 18. Breastfeeding was established. 19. There is no acute complaint such as fever, vaginal discharge or tenderness at site of operation (if LSCS). Check: Hand, conjunctiva - pale Breast - engorged Nipple - retracted, difficult to breastfeed Calf pain - calf non-tender, DVT especially in LSCS Advise on Pap smear, Rubella vaccine, Rhesus -ve
Contraception Counselling She wishes to have _______ children. / She claims her family is complete. After this pregnancy, she is keen on using _____________________ contraceptive because __________________________________. Space her pregnancy? I have explained the pro & cons of this method. She is aware of the effects & intends to use it for about _____ years. I have explained the importance of a well-spaced pregnancy.
OBSTETRIC PE SCRIPT On general examination, patient is pink/pale/jaundiced/cyanotic. Her BP was ___/___mmHg, pulse rate _____bpm, temperature ____C. Head, neck, heart, lungs & breasts showed no abnormalities.
Inspection 1. On abdominal examination, the abdomen is distended by a gravid uterus as evidenced by linea nigra & striae gravidarum. 2. Umbilicus is centrally located/otherwise & is flat/inverted/everted. 3. There is a transverse suprapubic scar measuring about 12cm which is well-healed/healed with keloid/hypertrophy. 4. The scar is tender/non-tender, no incisional hernia noted. 5. Say it if fetal movement is observed. Or else do not mention anything.
Palpation 1. The abdomen is soft & non-tender. Uterus is not irritable. 2. Clinical fundal height corresponds to ____w of gestation, equal/smaller/larger than date. 3. Symphysio-fundal height measured _____cm. 4. There is a single fetus/multiple pregnancy in longitudinal/transverse/oblique lie with cephalic/breech presentation. 5. Fetal back is at the maternal right/left side. 6. The head is ____/5 palpable, not/engaged, still ballotable. 7. Liquor is adequate/inadequate/excessive as evidenced by a positive fluid thrill. 8. Estimated fetal weight is _____kg. (multiple pregnancy - estimated combined fetal wt) 28w - 1.0kg 34w - 2.0kg 36w - 2.4kg Term - 3.2kg
Auscultation I would like to complete my examination by listening to the fetal heart using a Pinard stethoscope (>24w)/Daptone (<24w). I would listen over the anterior shoulder of fetus, around here (show to examiner).