Obs/Gyn: Antenatal Hx, Exam
  1. Introduction
  2. Past medical, surgical history, family history, social history
  3. Gynecological history, obstetrical history
  4. Current pregnancy: LMP, planned, confirmation, Rhesus/rubella, breastfeeding, antenatal care, pre-admission events hospital events
  5. Summary of history
  6. Examination: general, vitals, disease-specifics, inspection, palpation, auscultation, summary
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 || ...>.

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.

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>.

Her children are being looked after by
<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.

She
<is>
taking iron and folic acid supplements.

Gynecological history

With regards to
<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>.

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>.

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 ...>.

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>.

If a miscarriage, also brief:
<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>.

She has a
<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>.

Current pregnancy: planned

The pregnancy was
<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.

She booked into hospital at
<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>.

Current pregnancy: breastfeeding

She
<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>.

Current pregnancy: antenatal care

She opted for antenatal care with
<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>.

Current pregnancy: pre-admission events

<Mrs. Murphy>
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
<...>.

<Mrs. Murphy>
tells me that she is being kept in the hospital
<for observation>.

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.

The reason she is in hospital is
<a routine checkup || breech presentation || preeclampsia || diabetes || PROM || APH || ...>.

<Mrs. Murphy>
is being kept in the hospital
<for observation>.

Examination: general

<Mrs. Murphy>
looks
<clinically well>.

Examination: vitals

Her temperature is
<36.9 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 || ...>.

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.]

Examination: inspection

On inspection of the abdomen, there is an
<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.

There
<are no visible scars || are visible scars consistent with a prior...>.

There
<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.

The fetal parts that I feel in the fundus appear to be the
<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.

The presentation appears to be
<cephalic || breech || shoulder>.

The head
<is || is not>
engaged.

The fetus appears clinically
<normal || small || large>
in size.

The liquor volume appears clinically
<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>.

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>.