Beruflich Dokumente
Kultur Dokumente
B/O
Nor Malizah Binti Mamat
Nor Malizah binti Mamat
31 years old, G3 P2 @ 26W 1D
LMP : 3/8/16
EDD : 10/5/17
1ST SCAN : 12W 3D (p: 12W)
SS :19W 6D (p: 19W)
PLAN
BP monitoring
Monitor FHR 4hourly
Continue Adalat
IM Dexamethasone 12mg STAT and 12 hour later
For IV MgSO4 4g bolus, followed by 1g/hour infusion for 24H
KIV IV Hydralazine bolus if BP >150/100mmhg
Scan by MFM tomorrow
Watch out sign & symptoms of IE and MgSO4 toxicity
Repeat PE profile on 6/2/17
Nor Malizah binti Mamat
3/2/2017 (26W 2D) 31 years old, G3 P2
SEEN BY SPECIALIST
1710H
PLAN
Continue IV MgSO4 infusion to complete @ 1830H, to T/O ANW acute bed after completed
Continue T. Nifedipine 10mg TDS
For repeat scan + doppler by MFM in ward
Continue observation
SEEN BY MO
0825H
BS + IOL BY MO - 1/13
PGE 3MG INSERTED AT POST FORNIX
PLAN
Rest in bed for 1H
VE on strong contraction/SROM/6H post PGE insertion
SEEN BY SPECIALIST
1015H
No contraction/pv bleed
PLAN
Continue IOL
IM Pethidine PRN
SEEN BY MO
1430H
Post PGEx1
BS 4/13
2nd PGE 3mg inserted
Nor Malizah binti Mamat
8/2/2017 (27W) 31 years old, G3 P2
SEEN BY MO
0715H
BS 4/13
Membrane intact, placenta felt at right side
Offer IM Pethidine, patient keen.
SEEN BY SPECIALIST
1445H
BS- 4/13
No placenta tissue felt
PLAN
Repeat BS CM by specialist
VE on strong regular contraction
IM Pethidine PRN
Nor Malizah binti Mamat
9/2/2017 (27W 1D) 31 years old, G3 P2
SEEN BY SPECIALIST
0950H
PLAN
T. Nifedipine 10mg TDS
Post SVD medication,T. Carbogeline 0.5mg STAT
For T. Aspirin 7mg OD on next pregnancy
T/O gynae ward, acute bed
For APS screening 6/52 postpartum
10/2/17
SEEN BY SPECIALIST
0910H
31 YO PARA 3
*patient request to go back home to take care of
DAY 1 POST SVD WITH INTACT PERINEUM other children
WITH UNDERLYING SEVERE IE
CURRENTLY
No IE symptoms
Latest BR controlled
Urine albumin: nil
BP Range (110-140/60-80)mmHg
VITAL SIGNS:
Stable PLAN
To inform KK for EOD BP monitoring
P/A: To start T Aspirin on next pregnancy
Soft Non Tender TCA 1/12 PNC HTAA
Uterus @ 16W size Continue T. Nifedipine
Well contracted Allow Discharge
DOCUMENTATION OF CASES OF IUD (MSB/FSB)
BY MO
B/O NOR MALIZAH BINTI MAMAT
RN 1008028
FETUS :
WT : 500 GRAM
APPEARANCE : MACERATED
HEAD : NORMAL
NECK : NORMAL
CHEST : NORMAL
ABDOMEN : NORMAL
*CARDIAC BLOOD FOR C+S & TORCHES
GENITALIA : FEMALE CANNOT BE SENT BECAUSE OF INADEQUATE
ANAL PATENCY : YES SAMPLE
LIMBS : NORMAL
HANDS, FEET,DIGITS : NORMAL
CORD LENGTH : 30CM
VESSEL : NORMAL
PLACENTA : 190 GRAM
SITE OF CORD INSERTION : PLACENTAL INFARCT AND CALCIFICATION
RETRO-PLACENTAL CORD : NO