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.
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.
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.
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 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
