Obs & Gynecology:Antenatal Examination
Introduction
This is <Mrs.Murphy> ,a
<28 year old> <schoolteacher> ,from <Dublin>
,who is <38 weeks pregnant>with her <third>
baby. The reason she is in hospital is
<a routine checkup || breech presentation || preeclampsia || diabetes || PROM || APH || ...>.
baby. The reason she is in hospital is
<a routine checkup || breech presentation || preeclampsia || diabetes || PROM || APH || ...>.
Current pregnancy: planned
The
pregnancy was
<planned || unexpected>
and
<Mrs. Murphy>
<was || was not>
taking periconceptual folic acid.
<planned || unexpected>
and
<Mrs. Murphy>
<was || was not>
taking periconceptual folic acid.
[If
contraception like OCP failed, you may wish to ask her why it didn't work].
Current pregnancy: confirmation
She had a
positive pregnancy test at
<5>
weeks.
<5>
weeks.
She booked
into hospital at
<13 weeks>
and an ultrasound scan
<confirmed her menstrual dates>.
<13 weeks>
and an ultrasound scan
<confirmed her menstrual dates>.
<She
felt quickening at ... weeks>.
Current pregnancy: Rhesus/rubella
She is
<Rhesus positive || Rhesus negative || uncertain of her Rhesus status>
and
<rubella immune || not rubella immune || uncertain of her rubella status>.
<Rhesus positive || Rhesus negative || uncertain of her Rhesus status>
and
<rubella immune || not rubella immune || uncertain of her rubella status>.
Current pregnancy: breastfeeding
She
<breastfed || bottlefed>
her previous children and intends
<breastfeeding || bottlefeeding>
for this baby.
<breastfed || bottlefed>
her previous children and intends
<breastfeeding || bottlefeeding>
for this baby.
If
breastfeeding and first child:
<She is comfortable with breastfeeding because she has taken a class>.
<She is comfortable with breastfeeding because she has taken a class>.
Current pregnancy: antenatal care
She opted
for antenatal care with
<her general practitioner || this hospital>.
<her general practitioner || this hospital>.
Her
antenatal course was
<normal until she was admitted to hospital on this occasion || normal except for a ... at ... weeks gestation>.
<normal until she was admitted to hospital on this occasion || normal except for a ... at ... weeks gestation>.
Current pregnancy: pre-admission events
<Mrs.
Murphy>
was admitted to hospital
<4 days>
ago. She complained of
<...>
was admitted to hospital
<4 days>
ago. She complained of
<...>
Current
pregnancy: hospital events
Since
coming into hospital, the investigations she have had are
<....>
which showed
<...>.
<....>
which showed
<...>.
<Mrs.
Murphy>
tells me that she is being kept in the hospital
<for observation>.
tells me that she is being kept in the hospital
<for observation>.
Past medical surgical history
On
briefly reviewing Mrs. Murphy's past medical and surgical history...
Family history
In her
family history...
In
particular, there is
<no family history>
of diabetes, and
<no>
twins in the family.
<no family history>
of diabetes, and
<no>
twins in the family.
Social history
With
regard to social history,
<Mrs. Murphy>
works as a
<schoolteacher>.
<She also works at home looking after her children>.
She is due to go on a
<3 month>
maternity leave in
<1 week>.
She is residing in
<a 2 bedroom apartment>.
Her husband works as a
<lawyer>.
<Mrs. Murphy>
works as a
<schoolteacher>.
<She also works at home looking after her children>.
She is due to go on a
<3 month>
maternity leave in
<1 week>.
She is residing in
<a 2 bedroom apartment>.
Her husband works as a
<lawyer>.
Her
children are being looked after by
<the children's grandmother>.
<the children's grandmother>.
<Mrs.
Murphy>
<does not smoke || smokes ... cigarettes a day>
Prior to the pregnancy, she
<did not smoke || smoked ... cigarettes a day>.
She has
<not taken any alcohol || has restricted herself to ... units of alcohol per week>
since finding out she was pregnant.
<does not smoke || smokes ... cigarettes a day>
Prior to the pregnancy, she
<did not smoke || smoked ... cigarettes a day>.
She has
<not taken any alcohol || has restricted herself to ... units of alcohol per week>
since finding out she was pregnant.
She
<is>
taking iron and folic acid supplements.
<is>
taking iron and folic acid supplements.
Gynecological history
With
regards to
<Mrs. Murphy's>
past gynecological history...
<Mrs. Murphy's>
past gynecological history...
Her last
smear test was in
<1996>,
it was
<normal>,
and
<all of her smear tests have been normal>.
<1996>,
it was
<normal>,
and
<all of her smear tests have been normal>.
Obstetrical history
Turning
our attention to
<Mrs. Murphy's>
previous obstetrical history, she has
<two girls>,
aged
<2 and 4 years>.
They are
<both well>.
<Mrs. Murphy's>
previous obstetrical history, she has
<two girls>,
aged
<2 and 4 years>.
They are
<both well>.
If an
abnormal pregnancy, full details:
In her first pregnancy, she
<was induced>
at
<39 weeks>,
and after
<2 hours || 6 hours [depending on if making start of labour as when enter labour ward]>,
<under went a Cesarean section>
because of
<fetal distress>.
The cesarean section was performed
<under epidural>.
The baby weighed
<2.5kg>
at birth and
<was not admitted || was admitted for ... days>
to the neonatal unit.
She had
<no post-operative complications || post-operative complications of ...>.
In her first pregnancy, she
<was induced>
at
<39 weeks>,
and after
<2 hours || 6 hours [depending on if making start of labour as when enter labour ward]>,
<under went a Cesarean section>
because of
<fetal distress>.
The cesarean section was performed
<under epidural>.
The baby weighed
<2.5kg>
at birth and
<was not admitted || was admitted for ... days>
to the neonatal unit.
She had
<no post-operative complications || post-operative complications of ...>.
If a
normal pregnancy, brief:
In her second pregnancy, she
<went into spontaneous labor>
at
<40>
weeks
and had
<a normal vaginal delivery>.
The baby weighed
<3.0kg>.
In her second pregnancy, she
<went into spontaneous labor>
at
<40>
weeks
and had
<a normal vaginal delivery>.
The baby weighed
<3.0kg>.
If a
miscarriage, also brief:
<Mrs. Murphy>
also had
<1>
miscarriage
<14>
months ago
at
<10 weeks>
and
<underwent ERPC>.
<Mrs. Murphy>
also had
<1>
miscarriage
<14>
months ago
at
<10 weeks>
and
<underwent ERPC>.
Current pregnancy: LMP
Focusing
our attention on this pregnancy, the first day of
<Mrs. Murphy's>
last menstrual period was
<Sept 18th>.
She is
<certain || uncertain>
of the date, because she
<wrote it in her diary || remembers the day of conception>.
<Mrs. Murphy's>
last menstrual period was
<Sept 18th>.
She is
<certain || uncertain>
of the date, because she
<wrote it in her diary || remembers the day of conception>.
She has a
<regular>
<28 day>
cycle, and
<stopped the combined oral contraceptive pill>
<6 months>
before becoming pregnant.
<regular>
<28 day>
cycle, and
<stopped the combined oral contraceptive pill>
<6 months>
before becoming pregnant.
By
Nageles's rule, her estimated date of delivery is
<June 25th>.
<June 25th>.
Summary of history
In
summary, therefore, this is
<Mrs. Murphy>,
a
<28 year old>
<schoolteacher>,
from
<Dublin>,
who is
<38 weeks pregnant>
with her
<third>
baby.
<Mrs. Murphy>,
a
<28 year old>
<schoolteacher>,
from
<Dublin>,
who is
<38 weeks pregnant>
with her
<third>
baby.
The
reason she is in hospital is
<a routine checkup || breech presentation || preeclampsia || diabetes || PROM || APH || ...>.
<a routine checkup || breech presentation || preeclampsia || diabetes || PROM || APH || ...>.
<Mrs.
Murphy>
is being kept in the hospital
<for observation>.
is being kept in the hospital
<for observation>.
Examination: general
<Mrs.
Murphy>
looks
<clinically well>.
looks
<clinically well>.
Examination: vitals
Her
temperature is
<36.9º Celsius>.
Her pulse is
<80 bpm, regular rhythm, and normal character and volume>.
Her blood pressure is
<124/80>.
Her respiratory rate is
<18>.
<36.9º Celsius>.
Her pulse is
<80 bpm, regular rhythm, and normal character and volume>.
Her blood pressure is
<124/80>.
Her respiratory rate is
<18>.
Her urine
sample is
<normal || shows elevated <protein || glucose || ...>.
<normal || shows elevated <protein || glucose || ...>.
Examination: disease specifics
[If she
is in hospital for a disease, describe the relevant findings. For example, if
preeclampsia:
She has
<pedal edema || no evidence of pedal edema>
and her lower deep tendon reflexes
<are || are not>
elevated.]
She has
<pedal edema || no evidence of pedal edema>
and her lower deep tendon reflexes
<are || are not>
elevated.]
Examination:
inspection
On
inspection of the abdomen, there is an
<ovoid || globular>
swelling, consistent with
<the pregnant state || a ... trimester pregnancy>.
<ovoid || globular>
swelling, consistent with
<the pregnant state || a ... trimester pregnancy>.
There
<are || are no>
cutaneous signs of pregnancy, such as striae gravidarum and linea nigra.
<are || are no>
cutaneous signs of pregnancy, such as striae gravidarum and linea nigra.
There
<are no visible scars || are visible scars consistent with a prior...>.
<are no visible scars || are visible scars consistent with a prior...>.
There
<are || are no>
visible fetal movements.
<are || are no>
visible fetal movements.
Examination: palpation
[Ask
mother if tender anywhere on abdomen before touching, and also ask her to
mention any discomfort of if feel faint during the examination].
I
measured the symphysio-fundal height on the inches side to reduce observer
error, and found it to be
<38 centimetres>,
which
<is || is not>
compatible with gestation.
<38 centimetres>,
which
<is || is not>
compatible with gestation.
The fetal
parts that I feel in the fundus appear to be the
<breech>
as they are
<soft, irregular, and non-ballotable>.
<breech>
as they are
<soft, irregular, and non-ballotable>.
The lie
is
<longitudinal || transverse || oblique>
and the back would appear to be on the
<right || left>
as it offers more resistance to palpation and I feel small parts on the opposite side.
<longitudinal || transverse || oblique>
and the back would appear to be on the
<right || left>
as it offers more resistance to palpation and I feel small parts on the opposite side.
The
presentation appears to be
<cephalic || breech || shoulder>.
<cephalic || breech || shoulder>.
The head
<is || is not>
engaged.
<is || is not>
engaged.
The fetus
appears clinically
<normal || small || large>
in size.
<normal || small || large>
in size.
The
liquor volume appears clinically
<normal || reduced || increased>.
<normal || reduced || increased>.
[Some
obstetricians may ask about your liquor volume devining abilities:
"Really? The liquor volume is normal? Perhaps we should toss out our
expensive ultrasound and pay you instead." That is why it is important for
you to include "clinically" in the desciption-- it is "clinically
normal".]
Examination auscultation
The fetal
heart is best heard over the
<back>
and
<below the level>
of the umbilicus, and is
<normal>.
<back>
and
<below the level>
of the umbilicus, and is
<normal>.
Examination: summary
This is a
<singleton || multiple>
pregnancy,
<longitudinal || transverse || oblique>
lie,
<cephalic || breech>
presentation, the head
<is || is not engaged>,
the fetus is clinically
<normal || large || small>
in size, the liquor volume is clinically
<normal || reduced || increased>,
and the fetal heart is
<normal>.
<singleton || multiple>
pregnancy,
<longitudinal || transverse || oblique>
lie,
<cephalic || breech>
presentation, the head
<is || is not engaged>,
the fetus is clinically
<normal || large || small>
in size, the liquor volume is clinically
<normal || reduced || increased>,
and the fetal heart is
<normal>.
Postnatal Physical
Examination :
Introduction
This is
<Mrs. || Miss || Ms.>
<O'Connor>,
a
<34 year old>
<secretary>,
from
<Dublin>,
who delivered her
<first>
baby
<two>
days ago at
<40>
weeks gestation, a
<boy || girl>
named
<Clair>
by
<spontaneous vaginal || assisted vaginal || breech || Cesarean section>
delivery,
<is || is planning>
<bottle || breast>
feeding, and
<both baby and mother are well>.
<Mrs. || Miss || Ms.>
<O'Connor>,
a
<34 year old>
<secretary>,
from
<Dublin>,
who delivered her
<first>
baby
<two>
days ago at
<40>
weeks gestation, a
<boy || girl>
named
<Clair>
by
<spontaneous vaginal || assisted vaginal || breech || Cesarean section>
delivery,
<is || is planning>
<bottle || breast>
feeding, and
<both baby and mother are well>.
Past history
<She
is a longterm diabetic, which is successfully managed with insulin>.
<She had a PDA repair in 1969>.
<In her Obstetric history, her prior child had congenital deafness>.
<Her mother and 3 sisters all had at least one post-partum hemorrhage>.
<She had a PDA repair in 1969>.
<In her Obstetric history, her prior child had congenital deafness>.
<Her mother and 3 sisters all had at least one post-partum hemorrhage>.
<She
smoked one pack a day since she was 16, but since finding out she was pregnant,
she has limited herself to one or two cigarettes per week>.
<Before her pregnancy she consumed 3 units of alcohol per week, but she has not taken any alcohol since finding out she was pregnant>.
<She is not on any medications, and she has no allergies>.
<Before her pregnancy she consumed 3 units of alcohol per week, but she has not taken any alcohol since finding out she was pregnant>.
<She is not on any medications, and she has no allergies>.
Current pregnancy
First day
of her LMP was
<November 20th>
and she is
<certain || uncertain>
of her dates, because
<she wrote it in her diary || remembers the time of conception>.
By Nagele's rule, her estimated date of delivery is
<August 27th>.
An ultrasound scan at
<13 weeks>
<confirmed her dates>.
<November 20th>
and she is
<certain || uncertain>
of her dates, because
<she wrote it in her diary || remembers the time of conception>.
By Nagele's rule, her estimated date of delivery is
<August 27th>.
An ultrasound scan at
<13 weeks>
<confirmed her dates>.
Her
pregnancy was
<uneventful, except for a .... at 35 weeks gestation>.
<uneventful, except for a .... at 35 weeks gestation>.
She is Rhesus
<positive || negative>
and
<is || is not>
Rubella immune.
<positive || negative>
and
<is || is not>
Rubella immune.
Labour: onset/duration
<Mrs.
O'Connor's>
labour began with
<painful uterine contractions ... minutes apart, increasing in duration and frequency>
at
<1:00 am on Tuesday morning>
followed by
<a show and spontaneous rupture of membrane || a show but no spontaneous rupture of membrane || a spontaneous rupture of membrane || neither show nor spontaneous rupture of membrane>.
She was admitted to hospital at
<8:45 am>
by which time her cervix had dilated to
<3 cm>.
labour began with
<painful uterine contractions ... minutes apart, increasing in duration and frequency>
at
<1:00 am on Tuesday morning>
followed by
<a show and spontaneous rupture of membrane || a show but no spontaneous rupture of membrane || a spontaneous rupture of membrane || neither show nor spontaneous rupture of membrane>.
She was admitted to hospital at
<8:45 am>
by which time her cervix had dilated to
<3 cm>.
She was
admitted to the antenatal ward. She was examined by the
<midwife>
and her cervix was found to be effaced and cervix dilated to
<7cm>.
A diagnosis of labour was made, and she was sent to delivery.
<midwife>
and her cervix was found to be effaced and cervix dilated to
<7cm>.
A diagnosis of labour was made, and she was sent to delivery.
The first
stage lasted for
<2 hours [some hospitals specify labour as time from admission to labor unit] || 9 hours>,
the second stage lasted for
<20 minutes>.
<2 hours [some hospitals specify labour as time from admission to labor unit] || 9 hours>,
the second stage lasted for
<20 minutes>.
She was
given
<10 units/1000mL IV of oxytocin || 500 micrograms/1ml IM of ergometrine>.
<10 units/1000mL IV of oxytocin || 500 micrograms/1ml IM of ergometrine>.
Labour: analgesia
For
anaglesia, she first tried
<Nitrous oxide by inhalation>,
but subsequently requested
<an epidural at 8:45am>
which
<gave adequate analgesic relief for the duration of labour>.
<Nitrous oxide by inhalation>,
but subsequently requested
<an epidural at 8:45am>
which
<gave adequate analgesic relief for the duration of labour>.
Labour: fetal signs
The
liquor was
<clear throughout || green throughout || clear, then green>.
<clear throughout || green throughout || clear, then green>.
Optionally:
<a cardiotocograph was connected during the labour, and intermittent auscultation was performed>.
<a cardiotocograph was connected during the labour, and intermittent auscultation was performed>.
Electronic
fetal monitoring
<was not performed || <was performed due to:
<prolonged labor || suspected small for dates || prematurity || APH>>.
Fetal blood sampling
<was not done || was done to look for ...>
<was not performed || <was performed due to:
<prolonged labor || suspected small for dates || prematurity || APH>>.
Fetal blood sampling
<was not done || was done to look for ...>
Labour: delivery/infant
The
delivery was
<spontaneous vaginal || vaginal instrumental || breech || Cesarean section>
with
<a ... degree tear || <midline || mediolateral> episiotomy requiring ... stitches || no tears or episiotomy required>
at
<2:45pm>.
<Claire's>
condition at birth was
<normal, crying immediately at birth || ...>,
and weighed
<3 kg>.
A pediatrician
<was || was not>
present at the time of delivery.
<Claire>
<was admitted to the neonatal unit || went with her mother to the postnatal ward>.
<spontaneous vaginal || vaginal instrumental || breech || Cesarean section>
with
<a ... degree tear || <midline || mediolateral> episiotomy requiring ... stitches || no tears or episiotomy required>
at
<2:45pm>.
<Claire's>
condition at birth was
<normal, crying immediately at birth || ...>,
and weighed
<3 kg>.
A pediatrician
<was || was not>
present at the time of delivery.
<Claire>
<was admitted to the neonatal unit || went with her mother to the postnatal ward>.
Maternal history: lochia
Her
lochia is currently
<red || brown || white>,
<is odourless || has a pungent odour>,
<has no clots || has some clots>,
<is less || is more>
than a period,
and is
<getting less each day>.
<red || brown || white>,
<is odourless || has a pungent odour>,
<has no clots || has some clots>,
<is less || is more>
than a period,
and is
<getting less each day>.
Maternal history: pelvic pain
Mrs.
O'Connor has
<no pelvic pain || is experiencing some pelvic pain which she describes as ...>
<no pelvic pain || is experiencing some pelvic pain which she describes as ...>
Maternal history: restored function
Since
returning from delivery, she is
<now ambulatory || not yet ambulatory>,
<has passed her bowels || has not yet passed her bowels>,
<has no flatus || is experiencing some flatus>,
and
<has voided her bladder || has not yet voided her bladder>.
<now ambulatory || not yet ambulatory>,
<has passed her bowels || has not yet passed her bowels>,
<has no flatus || is experiencing some flatus>,
and
<has voided her bladder || has not yet voided her bladder>.
Maternal examination: affect
<Mrs.
O'Connor>
looks
<clinically well>
and appears
<happy>
with her baby.
[This is a more polite way to descibe that she is not experiencing any postpartum depression/psychosis.]
looks
<clinically well>
and appears
<happy>
with her baby.
[This is a more polite way to descibe that she is not experiencing any postpartum depression/psychosis.]
Maternal examination: vitals
Her
temperature is
<36.9º Celcius>.
Her pulse is
<80 bpm, regular rhythm, and normal character and volume>.
Her blood pressure is
<124/80>.
<36.9º Celcius>.
Her pulse is
<80 bpm, regular rhythm, and normal character and volume>.
Her blood pressure is
<124/80>.
Maternal examination: general
She has
<no signs of anemia || signs of anemia including...>.
<no signs of anemia || signs of anemia including...>.
Maternal examination: chest
Her chest
is
<clear, with good air entry bilaterally, and no added sounds>.
Her respiratory rate is
<18>.
<clear, with good air entry bilaterally, and no added sounds>.
Her respiratory rate is
<18>.
Maternal examination: legs
There
<are || are no>
signs of DVTs, such as asymmetric: size, color, or temperature. There
<are || are no>
signs of superficial thrombophebitis.
<are || are no>
signs of DVTs, such as asymmetric: size, color, or temperature. There
<are || are no>
signs of superficial thrombophebitis.
Maternal examination: abdomen
On
inspection of the abdomen, it is distended
<below || above>.
the umbilicus. It
<moves || does not move>
with respiration, and
<no scars are visible || there is a visible cesarean and episotomy scar that is...>.
<below || above>.
the umbilicus. It
<moves || does not move>
with respiration, and
<no scars are visible || there is a visible cesarean and episotomy scar that is...>.
On
palpation of the abdomen, the fundus is
<2>
fingerwidths below the umbilicus.
<It is less than the expected 1 cm/day, possibly due to a full bladder as she has not voided in the last 8 hours>.
The fundus is
<normal size and shape || ...>,
<mobile || immobile>,
<regular || irregular>,
<firm || soft>,
and
<nontender || tender>.
<2>
fingerwidths below the umbilicus.
<It is less than the expected 1 cm/day, possibly due to a full bladder as she has not voided in the last 8 hours>.
The fundus is
<normal size and shape || ...>,
<mobile || immobile>,
<regular || irregular>,
<firm || soft>,
and
<nontender || tender>.
If a
Cesarean section was done:
The incision site appears to be
<healing well>.
The incision is
<red>,
the edges are
<well opposed>,
and there are
<stitches || stitches and steristrips>
in place.
There is
<no discharge or other signs of infection>.
There is
<no extreme abdominal distention>,
and bowels sounds are
<present and normal>.
The incision site appears to be
<healing well>.
The incision is
<red>,
the edges are
<well opposed>,
and there are
<stitches || stitches and steristrips>
in place.
There is
<no discharge or other signs of infection>.
There is
<no extreme abdominal distention>,
and bowels sounds are
<present and normal>.
Baby
<Clair>
appears
<well, moving all four limbs, ...> :
appears
<well, moving all four limbs, ...> :
If bottle
feeding:
<Clair>
is bottle feeding, taking
<SMA || Cow and Gate || ...>,
<50 mL>
per feed, feeding
<well>
every
<4>
hours, and is
<wetting her nappies [alternatively: if <3 days, can say "passing meconium and urine"]>.
<Clair>
is bottle feeding, taking
<SMA || Cow and Gate || ...>,
<50 mL>
per feed, feeding
<well>
every
<4>
hours, and is
<wetting her nappies [alternatively: if <3 days, can say "passing meconium and urine"]>.
If breast
feeding:
<Clair>
is breast feeding
<8>
times a day
<and through the night>,
feeding
<on demand || by docking>,
with each feed lasting
<10 minutes, with 5 minutes per side>.
<Clair>
<is satisfied>
with her feed, and her nappies
<are wet>.
<Mrs. O'Connor>
<feels || does not feel>
her breasts empty and swell,
<has no nipple concerns, and>
<is comfortable taking Claire on and off, as she went to a class>.
<Clair>
is breast feeding
<8>
times a day
<and through the night>,
feeding
<on demand || by docking>,
with each feed lasting
<10 minutes, with 5 minutes per side>.
<Clair>
<is satisfied>
with her feed, and her nappies
<are wet>.
<Mrs. O'Connor>
<feels || does not feel>
her breasts empty and swell,
<has no nipple concerns, and>
<is comfortable taking Claire on and off, as she went to a class>.
If
nation's protocol is for BCG vaccination and/or Guthrie tests:
<Clair>
<had || is scheduled for>
her BCG on
<Tuesday>,
and her metabolic screen is on
<Wednesday>.
<Clair>
<had || is scheduled for>
her BCG on
<Tuesday>,
and her metabolic screen is on
<Wednesday>.
Contraception / parenting / PT
After
pregancy, she
<will || will not>
<start on || go back on>
<the combing oral contraceptive pill in 4 weeks time [alternatively: starting on the day of her next period] || ...>,
<as it has offered good prote
Source: www.doctorshangout.com
<will || will not>
<start on || go back on>
<the combing oral contraceptive pill in 4 weeks time [alternatively: starting on the day of her next period] || ...>,
<as it has offered good prote
Source: www.doctorshangout.com
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