Bentong KK - MCH

Name: NORADILLA BINTI ABDULLAH

Gender: Female Age: 27 Yr(s) 11 Mth(s)
ID Number: 871201115538 (NRIC) Race:
Malay
Date Captured: 27/11/2015 Time Captured:
10:15
Captured By: DR. ARINDERPREET KAUR
History of Present Illness:
Associated Symptoms :
24 years , G2 P1 @ 37 WEEKS + 3
DAYS 1) Poor spacing 2) 1 previosu
scar in 2014 for fetal distress @ hosp
teluk intan 3) Mild anemia in pregnancy
latest hb 11 , no s/s anemia 4) Wrong
dates patient unsure of dates , claims
after the 1st pregnancy period irregular
- 1st scan 11wks +1 day redd 15/12/15
- 2MD REDD 18WEEKS +6 DAYS
TODAY CAME FOR RME 2 -NO PV
BLEED -NO PV DISCHARGE -NO UTI
SX -GOOD FETAL MOVEMENTS
-LATEST HGB:11.0 -NO S/S OF
LABOUR :

Physical Examination:
Vital Signs and Anthropometry Date
Captured: 27/11/2015, Time Captured:
09:46
Vital Signs:
BP (Sitting): 110 / 70 mmHg

Physical Examination
General: looks well,pink,normal
and capillary refill time < 2
seconds,normal
hydration,appropriate growth and
build,well
Oedema: none
Cardiovascular: normal
examination
Respiratory: normal examination
and comfortable
Breasts: normal examination
Abdominal Examination:
Uterus: Palpable.
Fundal height: 36 cm
Abdominal Tenderness: No
Caesarean Scar Tenderness: No
Liquor: Normal
Foetal Information:
1. Lie: Longitudinal,
Presentation: Not Applicable,
Head Engagement: Not Applicable,
Head Position: Not Applicable
Foetal Heart: Present,
Foetal Movement: Present,
USS Details:
USS Result 1.
Ultrasound Type : Abdominal
Baby Number : I
Presentation : Cephalic
Placenta : Posterior Upper Segment
Lie : Longitudinal
Foetal Anomaly : Absent
Foetal Heart : Present
BPD : 90 mm 36 weeks 6 days
FL : 71 mm 36 weeks 4 days
AC : 321 mm 36 weeks 0 days
HC : 325 mm 36 weeks 5 days
AFI : 15.8

EBW : 2970 gms

Diagnosis:
Confirmed Diagnosis: Encounter for
antenatal screening. Diagnosed since 2015
Confirmed Diagnosis: Encounter for
antenatal screening.
Remarks:
REPEAT SCAN AT REDDP- 15/12/15
- PATIENT KEEN FOR DELIVERY AT
JB - FOR SCAN AT REDD IN JB
ALLOW TOS AS PLAN
CONTINUE ANC
CONTINUE HEMATINCS
TCA STAT IF
-PV BLEED
-LEAKING LIQUOR
-CONTRACTION PAIN
-REDUCED FETAL MOVEMENTS