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Presentation Script Obs

This document contains two scripts: (1) an antenatal presentation script introducing a pregnant patient and providing her medical history and current pregnancy details, and (2) a postpartum delivery script providing details of a normal vaginal delivery, including the newborn's condition, blood loss, and the mother's post-delivery status and care.

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Ck Kma
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© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
516 views

Presentation Script Obs

This document contains two scripts: (1) an antenatal presentation script introducing a pregnant patient and providing her medical history and current pregnancy details, and (2) a postpartum delivery script providing details of a normal vaginal delivery, including the newborn's condition, blood loss, and the mother's post-delivery status and care.

Uploaded by

Ck Kma
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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(A) Obstetrics Presentation Script (Antenatal) INTRO This is madam __ A __year old lady, gravida __ parity ___.

LMP on _____ and EDD is on ____ POA is ____. HOPI She was admitted on ___ due to _____ from ______ (was referred from _____) Menstrual Hx She attained menarche at the age of ___. It is regular/irregular at ___ days per months cycles / with ___ days of menses. Menses was normal/ large volume fully soaked and there was dysmenorrhoea. The last menses was ____. Past Obstetrics Hx This is her ___ pregnancy @ she has ____ children with ___ boys and ___ girls and all of them are ____. All of them were delivered via FTSVD/ LSCS and birth weight range up from ___ to ____. There is/no Hx of premature labour. Hx of Present Pregnancy This is expected/unexpected/pregnancy but wanted/unwanted. She did book up/ late booking at ___ of POA at ___. She had ___ visits and all of them were uneventful. PO/M/SHx She had Hx of DM/HTN/Heart diseases/asthma/bleeding tendencies, allergic to drugs/anaesthesia. She had/never had PAP smear before and the result was ____. S & FHx There is/ no FHX of HTN, DM, multiple pregnancy, breech/ LCSC. She works as a ____ at ___ and earns ____ per month. She is a / non smoker or consume alcohol. Her husband works as __ at __ with RM ___ /month salary. The family income is RM ___/month.

(B) Post ops delivery script of clerking (normal delivery) 1. Madam __ , ___ yo para ___ work as __ admitted at ___/52 POA in active phase of labour 2. She delivered vaginally after __ hrs of active phase, labour following augmentation of labour by ___/required forceps/ vacuum delivery. 3. She had delivered a __ baby with weight of __ kg with APGAR score ___ in 1 min and ___ in 5 min. 4. Amount of blood loss __ ml, placenta weight __ kg. 5. No intrapartum/postpartum complication noted. 6. Today pt is well/pallor /with vital sign are stable (BP, PR, temp) 7. Uterus is well contracted and __ /52 in size 8. Lochia is normal with ambulatory well 9. Breast feeding was established. 10. Pt takes __ orally, pass urine, bowel habit, contraceptive plan.

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