Obstetrics Clerking Sheet

INTRO:
1. My patient, Madam ______________________________________, a _____y/o lady,
working as a ______________________, from _____________ G___P___ currently
at ________weeks of gestation, with a known case of _________________________,
is admitted for ________________________________ associated with
_______________________________ on _______ at time______.
2. Her LMP was on __________, EDD is on _____________. REDD ______________.
CHIEF COMPLAINTS:
________________________________________________________________________
________________________________________________________________________
HISTORY OF PRESENTING ILLNESS:
Site:
Onset:
Character:
Associated Symptoms:
Duration:
Exacerbating/ Relieving Factor:
Severity:
Any procedure/ investigation done? (After admitted)
Any treatment given?
Outcome of investigation & treatment
Any further planning? (What the doctor gonna do) (eg: give antibiotic, CTG, vaginal
examination, scan- AFI, blood test, induction of labour etc.), Next review? (What time)
Progression of the patient condition (eg: will there risk of infection etc.)
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ANTENATAL HISTORY & HISTORY OF PRESENT PREGNANCY (HOPP)
1. This is an un/planned & un/wanted pregnancy.
2. Her urine pregnancy test was tested positive at ______week of gestation.
3. The early part of the pregnancy was a/w excessive vomiting but did not require any
admission/ medication. (and other pregnancy indicative symptoms)
4. Initial booing was done at _____weeks of gestation, date: _________ at
________________________.
5. Dating scan was done at ______week of gestation, date: _________ at
_____________________. The date corresponding to actual week of gestation or not?
a) Her weight at the time was ______kg, height ______cm, BMI ______.
b) Her BP was _____/_____mmHg, Hb _______g/dL, blood group ___________.
c) Urine test normal/ showed proteinuria/ glycosuria.
d) Hep B/ HIV/ VDRL Screening was NR/ Reactive for ______________________.
e) MGTT was not/ done _______ times because of _______________, was normal/
showed signs of hyper/hypoglycaemia. Results are ____________.
f) This was followed by Blood Sugar Profile (____/____/____/____) taken at _____
weeks. ****Maybe a normal blood sugar test (not necessary MGTT or BSP)
6. Since then, she had a total of _____ follow ups (Jumpa doctor) once per month,
______ weeks’ gestation onwards _______ times per month. All were uneventful.
7. Total _______ scan is done. Her latest scan was done at _____ weeks POA at
____________________ showing parameters equal to date, single/ multiple fetus,
fetal presentation __________________, ________________ lie, placenta at
________________, amniotic fluid index (AFI) _________, and estimated fetal
weight _____________kg.
8. The pregnancy has progressed well. She gained weight _________kg,
in/appropriate/corresponding to the progress of her pregnancy.
9. She had several ultrasounds performed, date ____________ at __________________
and was told the baby was growing well. Up till today, fetal movements were good
and there were no signs of labour.
10. Quickening = ______________
11. Tetanus toxoid (when) = ___________
12. She uses contraception _______________________ from _________ to __________.
If unplanned pregnancy, ask why suddenly stop using. Or she denies using
contraceptive methods.
13. Subfertility? (ask if no conceive even no use contraceptive) – married how long?
PAST OBSTETRICS HISTORY:
Year Boy/Girl Mode Reason Weight Term Alive/ Death Cx

Status of her children recently? Breasting feeding? If yes, how long for each children?
Born where?
She had delivered _____ children, ____ boys and ______ girls. All of them were delivered
via FTSVD or except for ______ child which was delivered by LSCS due
to_____________________.
The post-operative period was uneventful.
The babies weighted between ____ to ____ kg. All children are normal, alive and well.
If miscarriage: She had a history of miscarriage in _____ th pregnancy at _____ weeks
POA, confirmed by ultrasound. An Evacuation of Retained Products of Conception (ERPOC)
was performed and there was no complication following the procedure.
If intrauterine death (IUD): She had a history of IUD in ____th pregnancy at _____ weeks
of POA. There was no precipitating factor and it was diagnosed following a complaint of
decreased fetal movements. The delivery was induced and 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 irregular/regular with _______ day’s cycle with
normal/ minimal flow for ______ days.
3. No dysmenorrhea and menorrhagia.
4. No history of UTI/ STD.
5. Pap smear has never/ done on ________________ showing __________________.
MEDICAL HISTORY
No history of DM, HTN, asthma, renal disease, thyroid and drug allergy. (If yes, the severity?
Experience of refer to other hospital.)
She is a known ________________________ diagnosed since ___________.
The patient is on ______________________ medication. How is the patient compliance???
How the follow up done? (eg: see doctor how frequent, any further or change in medication
& treatment.)
__________________ is now/ well controlled. No complications secondary to the disease.
SURGICAL HISTORY
There is no significant surgical history.
She is a known case of _____________ and had undergone ____________ in __________,
and the outcome is _______________. She is now _______________ and does not require
any medication.
Appendectomy? Laparoscopy? Salpingectomy?
FAMILY HISTORY
Her father__________________________________________________________________
Her mother_________________________________________________________________
All other family members are healthy.
If any complication, how well they manage it? Treatment progress?

SOCIAL HISTORY
She is a _____________________, married to a ____________________ in __________,
______________ years.
Their total/ gross income is RM ___________per month.
They live at Taman __________________, Sungai Petani, together with her husband/
parents/other family members.
House near town/hospital/ any facilities or not?
She claims not to smoke, drink and take any drugs/
Her husband also not to smoke, drink and take any drugs.
Currently, her children were taken care by ___________________.

Diet & drug history

SUMMARY OF HISTORY
My patient ____________________, a ______ y/o _________ lady, G___P___, working as a
_____________________, a known case of _______________________________________,
currently at ________ weeks of gestation, admitted for ______________________________,
a/w____________________________________ and awaiting delivery.
Addition: (you may ask if she having some complications such as GDM)
Antenatal history
Any appointment with specialist? When? What has been done? How many times?

For examination:
General & systemic review: most important is vital sign (BP, HR, RR), sign of anemia
(pallor), pedal edema. If nothing important or relevant, say “all general & systemic
examination review no abnormality, all finding confined to abdomen.”
 OBESTETRICS EXAMINATION SCRIPT
On general examination, patient is lying flat with one pillow below her head and she is
comfortable with this position and she is cooperative. She has no brannula/ IV setting on the
dorsum of the hand. The general appearance of the patient is normal. Patient is well built. She
is not dyspneic/tachypneic.
The palm of the patient is moist/dry, warm/cold, pinkish/pale. The nail of the patient is
pinkish in colour, no koilonychias (IDA), leukonychia, and the capillary refill time is less
than 2 seconds.
The pulse of the patient is_______ bpm. Volume adequate, synchronise (no radial pulse
delay), regular. Presence/absence of collapsing pulse.
No scar/ needle hole/wound around the arms.
There is no yellowish discolouration in the sclera which may indicate jaundice, and the
conjunctiva of the patient is not pale (anemia).
Oral hygiene of the patient is satisfied, there is no sign of central cyanosis, or pallor of the
tongue. Glossitis and Angular stomatitis are also present/absent.
There is no thyroid swelling in the neck region.
There is/ there is no bilateral pitting pedal edema.
INSPECTION
On inspection, the abdomen is distended with gravid uterus, evidenced by the presence of
linea nigra, striae gravidarum and striae albicans. There is superficial veins can be seen. The
umbilicus is centrally located, flat/inverted/everted. There is no/ there is previous scar
_____________________________________. There is no obvious fetal movement can be
observed.
PALPATION
Superficial palpation: ask patient is there any pain? Palpate the 9 quadrant. The abdomen is
soft and non-tender.
SFH is ____cm, **CFH is ____cm, which is corresponding to date/ smaller/ larger than date.
Flank fullness?
Two poles can be felt which indicates a singleton fetus, at which the fetus is in
_________________ lie, _________________ presentation with the fetal back on the materal
______________.
The head is engaged/ not engaged, ___/5 palpabl, still ballotable.
Liquor volume is adequate/ inadequate/ excessive as evidenced by positive fluid thrill.
AUSCULTATION
I would like to complete my examination by listening to the fetal heart using a Pinard
stethoscope (> 24 weeks)/ Daptone (< 24 weeks) at the anterior shoulder.