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    Bentong KKCCC

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    arinmaan
    This document summarizes a prenatal care visit for Noradilla binti Abdullah, a 27-year-old Malay woman who is 37 weeks and 3 days pregnant. She has a history of poor spacing between pregnancies and anemia. Her vital signs were normal. On examination, she had no issues and ultrasound found the fetus in cephalic presentation measuring 36 weeks and 6 days. She was diagnosed with an unremarkable antenatal screening and the plan is for her to continue prenatal visits and supplements, and to deliver at a hospital in Johor Bahru.

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    Bentong KKCCC

    Uploaded by

    arinmaan
    37 views1 page
    This document summarizes a prenatal care visit for Noradilla binti Abdullah, a 27-year-old Malay woman who is 37 weeks and 3 days pregnant. She has a history of poor spacing between pregnancies and anemia. Her vital signs were normal. On examination, she had no issues and ultrasound found the fetus in cephalic presentation measuring 36 weeks and 6 days. She was diagnosed with an unremarkable antenatal screening and the plan is for her to continue prenatal visits and supplements, and to deliver at a hospital in Johor Bahru.

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    This document summarizes a prenatal care visit for Noradilla binti Abdullah, a 27-year-old Malay woman who is 37 weeks and 3 days pregnant. She has a history of poor spacing between pregnancies and anemia. Her vital signs were normal. On examination, she had no issues and ultrasound found the fetus in cephalic presentation measuring 36 weeks and 6 days. She was diagnosed with an unremarkable antenatal screening and the plan is for her to continue prenatal visits and supplements, and to deliver at a hospital in Johor Bahru.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    37 views1 page

    Bentong KKCCC

    Uploaded by

    arinmaan
    This document summarizes a prenatal care visit for Noradilla binti Abdullah, a 27-year-old Malay woman who is 37 weeks and 3 days pregnant. She has a history of poor spacing between pregnancies and anemia. Her vital signs were normal. On examination, she had no issues and ultrasound found the fetus in cephalic presentation measuring 36 weeks and 6 days. She was diagnosed with an unremarkable antenatal screening and the plan is for her to continue prenatal visits and supplements, and to deliver at a hospital in Johor Bahru.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    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

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