HISTORY TAKING TEMPLATE

So I'm gonna share with you gaisss my template for clerking patient. Well, this is just a basic thing that you need to ask when you clerk a patient. In paediatric ward, you can't really take genuine history from the child. I mean, how you're gonna take history from a child right? They might be crying so loud that even the parent would thought you're an incompetent doctor at that time. Haaaa, so take history from the parent, NOT from their grandmother, their uncles, their sibling (depend on situation) or other unrelated people who came with the patient. Preferably take history from the mother. Mother know the best! They can provide all information you wanted to know. 

There are 2 templates that I did for my study purpose. 

• For template A, I put few things from Geeky Medic. Reference source is from Geeky Medic.
• As for template B, I re-edited it and followed a bit like Hospital Raja Perempuan Zainab (HRPZ) II history template. Reference source is from Geeky Medic.

1. TEMPLATE A 

2. TEMPLATE B

Topic : Postpartum Care by Association of Professors of Gynecology and Obstetrics (APGO)

Postpartum Maternal Physical Assessment Summary- BUBBLE HE

Breasts:

Uterus (Fundus):

Bladder:

Bowel:

Lochia:

• Persistent red lochia suggested delay involution that is usually associated with infections or retained piece of placenta tissue.
• Offensive lochia, which may be accompanied by pyrexia and a tender uterus, suggests infections and should be treated with broad spectrum antibiotics.
• Retained placental tissue is associated with increased red blood cell loss and blood clots, and this may be suspected if the placenta and membranes were incomplete at delivery. Management includes uses of antibiotics and evacuation of retained products under regional or general anaesthesia. 

Episiotomy 

Homan’s Sign-for DVT

Emotional State:

At my postpartum placement, one of the nurses gave us a very helpful handout on what to look for specifically in cesarean and vaginal deliveries postpartum.  Again, the Disclaimer is that these were tips she found useful in assessing her patients, do not use this information to guide your practice, checking college standards and organizational regulations is imperative to good practice. 

Vaginal Birth Assessment

1. VS: on admission; 1hr post 1st set of vitals; q4hrs for the next 48 hrs; qshift until d/c; within 2hrs of d/c
2. Urine Output: d/c foley catheter 12 hrs post opt unless ordered; output for first 2 voids should match ~30ml/hr; if no void within 6-8 hrs post foley removal then do I/O catheter
3. IV: assess for complications such as infiltration, fluid overload; d/c 24hrs or when stable VS

1. Check: GBS, Bloodtype, HepB, HIV and Rubella status of mother and baby
2. VS: on admission; qshift (if GBS+ive then q4h)
3. Head to Toe: on admission; qshift; the mother is a great resource wen you are doing vital assessments or when you are getting blood samples for the heel prick.  Have the mother hold the baby skin-skin or breast feed the baby when you assess, they cry less and will make the assessment go faster. 
4. Blood Work: GBS+ive babies need cbc and blood culture 4hrs after birth; bilirubine and newborn screen with heel prick is done after 24hrs for Vaginal births and 48hrs for Cesarean sections
5. Breastfeeding: skin-skin as much as possible; breask feed 12-3 hrs or when baby shows feeding cues.

Core module 12: Postpartum problems (the puerperium)

 

 

1. Self Assessment In O&G by Ten Teachers 1st Edition PDF
2. Self Assesement In 0&G by Ten Teachers 2nd Edition PDF
3. MCQ For MRCOG Part I PDF