Вы находитесь на странице: 1из 3

CLERKING GUIDE OBSTETRICS CASES

1. Per vaginal bleeding ( placenta previa)


2. Premature Rupture of membrane (PPROM), Preterm rupture of membrane
(PROM), spontaneous rupture of membrane (SROM)
3. Abdominal pain (Preterm contractions & Preterm labour , UTI, URTI)
4. GDM
5. HTN, Pre-eclampsia
6. Post date
7. Anencephaly
COMPONENTS IN CLERKING PROCESS
HISTORY
1.Pt details ( name,age,occupation,Gravida,LMP, EDD or rEDD, POA or
POG)
if history of +1; need to confirm either it is miscarriage,ectopic
pregnancy or molar pregnancy.
2.Chief complaints
3.History of presenting illness
Elaboration of complains
rule out differential diagnoses, causes,risk
Any previous admission
assess current fetal wellbeing ( fetal movement, quickening)
on any treatment?
History of previous problem in pregnancy
4. History of current pregnancy
Planned/unplanned pregnancy, days of missed period, any prior
UPT done at home.
Physical examination : height, weight, blood pressure
First ultrasound to confirm the gestational age of fetus ( single or
multiple fetus, any congenital anomalies)
Booking antenatal checkup when and where?( blood test, Hb,
blood grouping and rhesus typing)
Urinalysis
Supplement and tetanus toxoid injection 1st dose
Any plan for OGTT and indications
2nd trimester ; fetal kick chart ( completed 10 kicks at what time)
Follow up, uterus corresponds to fetal age
Tetanus toxoid injection 2nd dose ( 4 weeks before EDD)
Past medical and surgical history
Any previous medical/surgical disorders needing hospitalisation
5.Past obstetrics history
Age of first pregnancy, male/female term/preterm, born through
SVD or c-section (indication) with fetal weight on when, where.
Detailed history of any miscarriage ( type, any d&c done,
admission)
6.Past gynaecological history
Any pap smear was done( ujian pangkal Rahim) and results
Use COCP and if used, which method, successfulness and reasons.

Any gynaecological problems or procedure done ( fibroid, rupture


of ovarian)
7.Menstrual history
Age of attained menarchy
How long of menses ( duration of heavy menses and number of
soaked pads use)
Any menorrhagia, dysmenorrhea ( PMS symptoms and any
medication took for dysmenorrhea), intermenstrual bleed.
8.Family history
Ask about age and any medical conditions suffering by parents
No. of siblings
Any DM,HTN,renal/heart/liver failure, blood disorder
(thrombophilia, anemia, thalassemia), breast, cervical or
gynaecological malignancies.
9.Socioeconomic history
How long has been married ( fertility problems), age & occupation
of patient and husband, smoking or alcohol taken, financial
problems, own house or lives with family.
PHYSICAL EXAMINATION
General examination ( right side of patient) :
Inspection : patient is lying down on the bed, comfortable, conscious
and alert, not in respiratory distress, well build, hydration status,
height and weight (BMI)
Hand&palm : pink and warm, koilonychia, capillary refill time,
schamroths, fluctuation test for clubbing,
Haemodynamically : pulse rate, Blood pressure, temperature and
respiratory rate.
Eye : no anemia, no jaundice
Neck ( sitting position) : cervical lymphadenopathy and thyroid
swelling
Auscultation for heart sound and breath sound ( CVS& Respi) ; any
murmur or reduced heart sound
Leg : swelling and pedal edema
ABDOMINAL EXAMINATION :
Inspection : abdomen moves with respiration, umbilicus flat and
central, linea nigra seen, striae gravidarum&albican, any pfannenstial
scar,laparoscopic,midline or any other surgical scar, no dilated veins
and no fetal movement seen.
Symphysio fundal height (SFH) : in cm
Assess uterine size ( at which level)
Palpation ( ask patient if any pain at the abdomen, if any do palpate
from most away from pain) :
Fell for any superficial and deep tenderness, any mass
Leopold maneuver :
fundal grip ( fell for fetal pole either hard or firm, lateral grip for lie and
pelvic grip for presentation)

summary of palpation : there is single fetus, longitudinal lie, cephalic


presentation, fetal back at wich maternal side, engagement, liquor is
adequate or not, and estimated fetal weight.
If presence of contraction : feel for 10 minutes. Assess the intensity and
duration.
Auscultation : using pinard
I would like to end my examination with speculum and vaginal
examination.

Вам также может понравиться