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 || ...>.
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 pregnancyshe <did not smoke || smoked ... cigarettes a day>. She has <not taken any alcohol || has restricted herself to ... units of alcohol perweek> since finding out she was pregnant.
Turning our attention to <Mrs. Murphy's> previous obstetrical historyshe has <two girls> aged <2 and 4 years>. They are <both well>.
If an abnormal pregnancyfull details: In her first pregnancyshe <was induced> at <39 weeks> and after <2 hours || 6 hours [depending on if making start of labour as when enter labourward]> <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 pregnancybrief: In her second pregnancyshe <went into spontaneous labor> at <40> weeks and had <a normal vaginal delivery>. The baby weighed <3.0kg>.
If a miscarriagealso brief: <Mrs. Murphy> also had <1> miscarriage <14> months ago at <10 weeks> and <underwent ERPC>.
Focusing our attention on this pregnancythe first day of <Mrs. Murphy's> last menstrual period was <Sept 18th>. She is <certain || uncertain> of the datebecause she <wrote it in her diary || remembers the day of conception>.
She has a <regular> <28 day> cycleand <stopped the combined oral contraceptive pill> <6 months> before becoming pregnant.
By Nageles's ruleher estimated date of delivery is <June 25th>.
She is <Rhesus positive || Rhesus negative || uncertain of her Rhesus status> and <rubella immune || not rubella immune || uncertain of her rubella status>.
Her temperature is <36.9º Celsius>. Her pulse is <80 bpmregular rhythmand normal character and volume>. Her blood pressure is <124/80>. Her respiratory rate is <18>.
Her urine sample is <normal || shows elevated <protein || glucose || ...>.
[If she is in hospital for a diseasedescribe the relevant findings. For exampleifpreeclampsia: She has <pedal edema || no evidence of pedal edema> and her lower deep tendon reflexes <are || are not> elevated.]
[Ask mother if tender anywhere on abdomen before touchingand also ask her to mentionany discomfort of if feel faint during the examination].
I measured the symphysio-fundal height on the inches side to reduce observer errorandfound 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 <softirregularand 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 payyou instead." That is why it is important for you to include "clinically"in the desciption-- it is "clinically normal".]
This is a <singleton || multiple> pregnancy <longitudinal || transverse || oblique> lie <cephalic || breech> presentationthe head <is || is not engaged> the fetus is clinically <normal || large || small> in sizethe liquor volume is clinically <normal || reduced || increased> and the fetal heart is <normal>.
