Tiêu đề History Tips Dr Malini style ✅

For Revised EDD Ex: EDD was revised to ___ from ___ based on (when) ultrasound & was confirmed twice (if done 2x) Use apparently well Ex: my patient with ( disease if any ) was apparently well until she noticed mass per abdomen 3 years ago when she was lying down Don't use date instead make it in chronological order Ex: 3 years ago, 3 months ago Don't use electively admitted unless patient scheduled to be warded Ex: she was electively admitted for ELSCS When mentioning next symptoms, use at the same time Ex: she complained of urinary frequency and dysuria. At the same time, she had flank pain Don't use projectile vomiting for O&G cases, no brain tumour Don't just say patient has no fever, instead state the temperature, mention even if it’s low grade Ex: her temperature upon admission to the ED was 36.8 celsius, patient was afebrile Don't mention things that are not significant Ex: patient said she checked her temperature at home (fever), but later at clinic temperature normal (afebrile) then dont present that Use otherwise to mention negative findings Ex: otherwise, she was not having headache, frothy urine, dysuria Always try to exclude other dx when present to get extra marks Ex: on US, only single gestational sac was seen, no evidence of multiple pregnancy, no snowstorm pattern, no uterine mass, no pelvic abscess Don't say abdominal examination was done, instead Ex: abdominal examination revealed palpable mass per abdomen at suprapubic region Don't say cervical os was 2cm instead, use bishop score Ex: bishop score done, condition favourable Don't use the name of the medication if patient can't remember, instead Ex: patient was administered with IV antihypertensive agent Don't say urine sample was taken, be direct Ex: urine ketone was taken, result revealed 4+ Use luckily Ex: despite of her high BP, patient was not referred to tertiary hospital, luckily she did not develop (complications of HPT) Use despite compliance if condition does not improve even patient takes medication as instructed Ex: despite her compliance to 20mg methyldopa OD, her BP remained high Use probably when we trust that’s not what patient had Ex: patient hyperemesis said only multivitamin given, condition now improved, most likely, antiemetic was given, so use probably antiemetic Use plan for (procedure) Ex: due to no sx of labour at 39 weeks POG, patient is planned for IOL If patient on medication - how many times / day - since when - compliance - condition ( well optimised / not ) - ever changed the medication before / not