OBSTETRIC CLERKING SCRIPT
9. The pregnancy has progressed well. She gained weight ___kg, in/appropriate.
Intro & HOPI
10. She had several ultrasounds performed & was told the baby was growing well. Up until today, fetal movements were good and there were no signs of labour.
1. My patient, Madam ______, a _____ y/o lady, G__P__ currently at ____ weeks POA with a known case of ______ is admitted for ______.
Past Obstetric History
2. Her LMP was on _____, EDD is on _____, REDD _______.
Year| Age| SVD/CS| boy/girl| ___kg| POA/full term| Alive & well
Antenatal History
She had delivered __ children, __ boys & __ girls. Antenatally was un/eventful. All of them were delivered via FTSVD/except for __th child which was delivered by LSCS due to ____. The post-op/post-partum period was un/eventful. The babies weighed between __ to __ kg. all children are normal, alive, and healthy.
1. This is an un/planned & un/wanted pregnancy. 2. Her urine pregnancy test (UPT) was tested positive at ___w POA 3. Initial booking was done at ____w POA at _____. (a) Her weight at that time was ___kg, height ___cm, BMI ___kg/m2. (b) Her BP was __/__mmHg, Hb __g/dL, blood group ___, Rhesus +/(c) Urine test normal/showed proteinuria/glyosuria proteinuria/glyosuria
Miscarriage: She had history of miscarriage in _ pregnancy at __w POA, confirmed by ultrasound. An Evacuation of Retained Product of Conception (ERPOC) was performed & there was no complication following the procedure. Intrauterine Death (IUD): She had history of IUD I __th pregnancy at __w POA. There was no precipitating factor & it was diagnosed following complaint of decreased fetal movements. The delivery was induced & a baby boy/girl was delivered vaginally. The placenta had gross infarction.
(d) Hep B/HIV/VDRL screening was not/reactive for _____. (Add Past Gynaecological History
Thalassemia/BFMP if indicated). 1. She attained menarche at __y/o. (e) MOGTT was not/done ___times because ___ & the result was ___. (f) 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.
2. Since then her menses had been ir/regular with __ days cycle with normal/minimal flow for __ to __ days. 3. No/slight dysmenorrhea not requiring any medication/MC. 4. No history of intermenstrual,post-coital bleeding, menorrhagia, dyspareunia.
5. Quickening was felt at ___w POA. 5. No history of UTI/STD. 6. ATT injection was administered once/twice at ___&___w POA. 6. Pap smear has never/done on __ showing ____. 7. Since then, she had a total of ___ follow ups once per month, ___w POA onwards ___ times per month. All were were uneventful. 8. Her latest scan was done at ___w POA at ______ showing parameters equal to date, single/multiple fetus, cephalic/breech presentation, in longitudinal/transverse/oblique longitudinal/transverse/oblique lie, placenta at ____, amniotic fluid index (AFI) ____ & estimated fetal weight is ___kg.
7. She uses contraception _______ from ___ to ____. 8. She does not use any contraceptive methods. 9. For subfertility, sexually active? Marriage how long? Long distance?
Medical History
Her BP is __/__mmHg, pulse rate __bpm, regular rhythm & good volume, temperature __C.
No history of DM, HPT, asthma, renal disease, drug allergy. Head, neck, CVS, Respiratory & breast shows no abnormalities. She is known diabetic diagnosed since _____. Inspection
The patient is on ___ m edication/vitamins (if any). Diabetes is not/well controlled. No complications secondary to the disease.
1. On abdominal examination, the abdomen is distended by a gravid uterus as evidenced by linea nigra & striae gravidarum.
Surgical History
2. Umbilicus is ce ntrally located/otherwise & flat/inverted/everted.
There is no surgery done before.
3. There is transverse suprapubic scar measuring about __cm which is well healed/healed with keloid/hypertrophy. keloid/hypertrophy.
She s known case of thyrotoxicosis & had undergone thyroidectomy in ___. She is now euthyroid & does not require any medication. Appendicectomy?
4. The scar is painful/less No incisional hernia noted.
Family History
5. Say it if fetal movement is observed, or else do not mention anything.
There s no family hx of DM, HPT, malignancy, congenital malformations, and twins.
Palpation
She has a strong family hx of _____.
1. The abdomen is soft & non-tender. Uterus is not irritable. Clinical fundal height corresponds to __w of gestation, equal/smaller/larger than date. Symphysio-fundal height measured __cm.
Both her parents *& ___ of her siblings are ____ & on treatment Father ___y/o , mother ____y/o Social History
She is a ______ married to a __ y/o _______ in _____. Their total income is RM _______. They live at _____ with/out elevator. She does not smoke/drink/drug. Husband does/not smoke/drink/drug. She wishes to have ___ children/says her family s complete. Currently her children are 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 _____ & awaiting delivery.
2. There is single fetus/multiple pregnancy in longitudinal/transverse/oblique lie with cephalic/breech presentation. 5. Fetal back is at the maternal right/left side. The head is _/5 palpable, not/engaged, still ballotable. Liquor is in/adequate/excessive evidenced by a positive fluid thrill. 8. Estimated fetal weight is __kg (multiple pregnancy – estimated combined fetal weight). 28w ~ 1.0-1.2 kg | 34w ~ 2.0-2.2 kg | 36w ~ 2.4-2.6 kg | Term ~ 3.0-3.2 kg Auscultation
I would like to complete my examination by listening to the fetal heart using a Pinard stethoscope (>24w) / Daptone (<24w). PHYSICAL EXAMINATION On general examination, pt is pnk/pale/jaundice/cyanot pnk/pale/jaundice/cyanotic. ic.
I would listen over the anterior shoulder of the fetus (line from ASIS to umbilical).
