DISCHARGE????

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)