Clerking Format for FEMALE PATIENTS (all, Obstetrics little different)

(INTRO)My Patient name is ………………………..,she is a (age)….. old (Race )……….. lady,  Gravida…….. Para……….   IF PREGNANT GRAVIDA ….,  IF NOT PREGNANT & HAS CHILDREN PARA………. .

She is known case of ……………..( any Medical Problem or issues) eg Diabetse for 10 years and Hypertensive for 3 years. If any MEDICAL PROBLEMS

EG Diagnose as pulm TB , 3 months ago and currently on anti Tb treatment

(CHIEF COMPLAIN)

She presented with history of ………………………………etc…EG.she presented with low grade fever & vomiting for 2 days

(HPI): HISTORY OF PRENSENT ILLNESS

Mrs ………. Eg  case describe c/o in detail, ass factors, aggravating & relieving factors

She was well until last Friday when she develop low grade fever, the fever was of sudden onset, there were no chills or rigor. She denied any body aches, headaches or pain behind her eyes( periorbital pain). The fever settle after one day but on the 2^nd day she experience severe vomiting

She vomited between 15-120 times, the vomitus is basically food & water she took, there is no bilous or blood in the vomitus. It was non projectile. There were no obvious aggravating factors. The vomiting slowly improved after taking some medication…….???

On further questioning, she denied any diarrhea, abdominal cramps or pain, she has no history of taking food in any unhygienic places.  Etc etc

Inview of this she seek medical advice from the health  clinic (KKIK……..) from there she was referred to serdang hospital for further management……… She has been in the ward for last 2 days. She was put on intravenous fluid & given some medication. She condition has improve since then. She has been investigated for………… &  what is the treatment & management in the hospital……………

SYSTEMIC REVIEW:…………………………………….No headaches, blurring of vision, no body rashes, etc etc related to your history

MENSTRUAL HISTORY

She attained her menarche at the age of 12 ( …….) age. The cycle has been regular with 28-30 cycles. Her flow is between 5-7 days. There were no menorrhagia (heavy period) or dysmenorrhea (painful periods). Her LMP (last Normal Menstrual Period ) is on the 12. October 2016. She is up to date with her pap smears. Her last pap smear was done in 2016, and she was told it was normal

PAST OBSTETRICS HISTORY

She is para 2, has 2 children age 7 & 2. Both the children were delivered by caesarean section for breech presentation ( baby upside down). The weigh 3 & 3.3 kg. There were no intrapartum & postpartum ( during & after delivery) complications. Both the children are well & alive. She breast fed her children for 6 months….( breast feeding or bottle feeding or mix)

In between pregnancy she took contraception ( OCP, IUCD etc…..)

(PAST MEDICAL HISTORY)

In terms of his past medical hIstory,  He  was diagnosed to have PTb in Sandakan , She was diagnose PTB after she presented with chronic cough & history of LOA, LOW…………, Full assessment was carried out & the diagnosis was confirmed by + sputum for AFB. She was subsequently started with anti-Tb treatment. She has taken the anti TB treatment for last 3 months at the chest clinic/ Health clinic. She is very compliant to the treatment. All her family members were screened & they tested negative.

 SHE IS NOT ALLERGIC TO ANY MEDICATIONS OR FOOD ( Better to put after medical h/o so don’t forget)

 PAST SURGICAL HISTORY

She never had any operations before………

If got operations…….. ? what op & years any complications ( eg……. She had 2 CSection on 2009 & 2017)

 FAMILY HISTORY

She is the youngest of 8 siblings / the third of 4 siblings. His parents are still alive & well. His mother is also diabetic but not hypertensive. His father has no medical illness. All his sibling is well and has no similar illness. There were no one in her family with PTB

 PERSONAL/SOCIAL HISTORY

She is married to EN………………………, she works as a………………., her partner works as……………………….. they live in a flat/ single storey teres / double storey teres/ single or double storey bungalow/condominium I ……………………………kajang/serdang………. The house is well  equipped with adequate basic amenities like water & electricity. Their combine monthly income is RM 2000. They have ……….children. She  and her partner does not smoke cigarette or consume alcohol. He also does not indulge in high risk behaviors’. She take s balance diet with 2-3 serving of meat per week. Recently after contracting with PTB she had loss about 3 kg

 IN SUMMARY, MY PATIENT  Pn/madam…………….., A KNOWN CASE OF DIABETES PTb diagnosed 3 months ago & still on anti-TB treatment presented with low grade fever with severe vomiting

 PROVISIONAL DIAGNOSIS:……………………………………………….

 DIFFERENTIAL DIAGNOSIS:1 …………………………………………

                                                        2………………………………………….

                                                       3. …………………………………………

HOW WOULD YOU MANAGE:………………………………………..

I would like to do some investigation:, l would like to do FBC to see any evidence of infection. I also would like to check his renal function to see if there any evidence of renal impairment. LFT to look for hypoalbuminemia. As per symptoms an ECG & Chest x-ray may provide me with any evidence of pleural effusion or cardiac failure. Others…………………………..

1.       Blood test FBC, RP, LFT …………whey & reasons

2.       Sputum AFB, C&S

3.       Cxray, ecg, echo whey & interpretations

4.       Other test d-dimer, Doppler studies, CT scan, MRI etc………..

5. The options for this patient are A. CONSERVATIVE MANAGEMENT LIKE...

                                                          B. MEDICAL TREATMENT LIKE.....

                                                          C. SURGICAL OPTIONS INCLUDING .........