Professional Documents
Culture Documents
9. The pregnancy has progressed well. She gained weight ___kg, in/appropriate.
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 ______.
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.
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.
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.
Inspection
Surgical History
She s known case of thyrotoxicosis & had undergone thyroidectomy in ___. She is
now euthyroid & does not require any medication. Appendicectomy?
Family History
Palpation
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.
PHYSICAL EXAMINATION
On general examination, pt is pnk/pale/jaundice/cyanotic.
I would listen over the anterior shoulder of the fetus (line from ASIS to umbilical).