PAC clerking
sb Dr Gibran at 0310H
Madam Siti Aishah
28years
G3 P1+1 at 39w with 1 previous scar
LMP: 25/11/10- sure of dates, regular menses, not on OCP
EDD: 02/09/11- confirmed by date, subsequent scans corresponds to date
HOPI
came in with complain of regular contraction
passed show
no leaking liquor
FM good
ANC
1.1 previous scar in 2008 for poor progress in HSB
- uncomplicated
- patient is counselled and agree for trial of scar during antenatal follow up
2. anaemia in pregnancy
booking HB 11.1, lowest Hb 9 at 34w,
supplemented with T ferrous fumarate, patient then started on IM
Imferon for 10/7 in view of symptommatic of anaemia (SOB, giddiness, latest Hb at 10 at 38weeks
booking at KK Serendah at
booking Hb 11.1, latest Hb 10
booking BP 110/70, normo tensive throughout
MGTT - excessive increase of maternal weight
at 25w: 3.8/4.2
at 33w: 4.2/6.8
BG: B+ve
HIV/VDRL: NR
o/e
alert
not pale
vitals
BP 119/73
PR 88
per abdomen
soft
uterus at term
singleton, longitudinal, cephalic
head 3/5th palpable
no scar tenderness
EFW 2.6-2.8 kg
VE
vulva vaginal normal
servix posterior, medium consistency, 1cm
Os 3cm
MI
vetrex
station -1
no cord, no placenta
CTG reactive
FHR baseline
acceleration seen
no deceleration
good variability
time contraction 2:10:20s
imp: GCP1+1 at 39w with 1 previous scar in latent phase of labour
plan
allow discharge with assurance
continue FKC at home
TCA stat if leaking liquor, strong contraction, reduce FM
nadia
26/8/11 @ 0330H
DR. NADIA MOHAMED
Pegawai Perubatan
Hospital Selayang
No. MMC: 41618 (Sementara)