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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

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 uneventful.
8. Her latest scan was done at ___w POA at ______ showing parameters equal to
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
No history of DM, HPT, asthma, renal disease, drug allergy.
She is known diabetic diagnosed since _____.
The patient is on ___ medication/vitamins (if any).

Her BP is __/__mmHg, pulse rate __bpm, regular rhythm & good volume,
temperature __C.
Head, neck, CVS, Respiratory & breast shows no abnormalities.

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 centrally 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.

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.


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
28w ~ 1.0-1.2 kg | 34w ~ 2.0-2.2 kg | 36w ~ 2.4-2.6 kg | Term ~ 3.0-3.2 kg
I would like to complete my examination by listening to the fetal heart using a
Pinard stethoscope (>24w) / Daptone (<24w).

On general examination, pt is pnk/pale/jaundice/cyanotic.

I would listen over the anterior shoulder of the fetus (line from ASIS to umbilical).