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Intro & HOPI

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 ____
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 ____
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 ___
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.

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 ____
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).
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.

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.

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.

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

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).