2018/2019

Patient Management Record for

Year 5 Clinical Posting Clerkship

INTERNATIONAL MEDICAL SCHOOL

MBBS YEAR 5 OCTOBER 2021/2022

PATIENT MANAGEMENT RECORD

OBSTETRICS & GYNAECOLOGY

NAME : NUR BATRISYIA HUSNA BINTI ZAINURIN

ID :
LECTURER : DR. MYO
DATE OF SUBMISSION : 22/2/2022
MOCK PATIENT RECORD
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Patient Management Record for

Year 5 Clinical Posting Clerkship

Patient particulars:
NAME: Aisyah Amirah GENDER: FEMALE
AGE: 32 years old D.O.B:
RACE: Malay RELIGION: ISLAM
DATE & TIME OF ADMISSION: DATE & TIME OF DISCHARGE:
8th Feb 2022, 5am 9th Feb 2022, 1.14pm
DISCIPLINE: WARD: 8A
OBSTETRIC & GYNAECOLOGY

PATIENT’S HISTORY:

Madam Aisyah Amira, 32 years old, primigravida, married, malay islam with period of
gestation 10 weeks 2 days, last menstrual period 24th November 2021 & estimated date of
delivery 31st August 2022. Date of admission was on 8th February 2022 at 5 pm & I clerk her
on 9th February 2022 at 9 am. She is warded at 8A ward bed 19.

History of presenting illness

Madam Aisyah, 32 years old, primigravida came to Emergency Department due to

nausea and vomiting for 1 month, worsening for 3 days prior to admission.

Regarding the vomiting, it was post prandial vomiting, non projectile in nature and
amount were about full toilet bowl each, it was associated with heartburn, gassy sensation and
aggravated with food intake. The content of vomit were just food and fluid content. No bile
stain or blood.

It was associated with nausea. She claimed that it was continuous throughout the day.
Other than that, she had 3 to 4 episodes of retching over the 3 days, on and off. She denied any
significant loss of weight. However, she had reduce oral intake and urine output. She only eats
twice a day and she only can tolerate breads otherwise she would vomit.

However, there was no history of eating outside food, fever, diarrhea, abdominal pain,
leaking of liquor, per vaginal bleeding, history of trauma and massage, she denied any taste of
sourness at the back of the throat, no fruity breath smell with fainting episode, no migraine, no
motion sickness, no anemic symptoms like shortness of breath, dizziness, lethargic and no
urinary tract infection symptoms like dysuria, urgency, increase in frequency, itchiness around
genital area and vaginal discharge.
Regarding to her, blood and urine test were taken at emergency department with
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Patient Management Record for

Year 5 Clinical Posting Clerkship

transvaginal ultrasound was done on her at Patient Assessment Centre (PAC). She has been
told that she had urinary tract infection based on the urine test result.

Upon clerking, she was well and hydrated and she claimed her vomit has become
better with no episodes and post prandial vomiting.

History of presenting pregnancy

1st trimester
 This is planned pregnancy.
 She noticed that she’s pregnant when she had spotting for 3 days and stop at day 4.
Then, she did a self Urine Pregnancy Test and it turns out positive. Regarding to her,
the spotting was just a small amount and brownish in colour.
 She had a dating scan at Klinik Kesihatan Shah Alam with Period of Gestation 5
weeks, viable intrauterine singleton embryo and estimated date of delivery is
correspond to Naegele’s rule.
 Booking visit was done at 9 weeks
 Blood group : A +
 Hb Level : 12.7 g/dl
 Height : 167 cm
 Weight : 59 KG
 Blood pressure and urine test was normal
 Screening test for HIV, VDRL, HBV was non reactive
 She was prescribed with obimin.

Past Obstetrics History

No Past Obstetrics History due to she is a primigravida.

Past Menstrual History

 She attained menarche at the age of 11 years old.

 Regular menses with duration 5-7 days every 28 days of cycle
 3 days of heavy flow with 3-4 pads changes meanwhile 2 pads on remaining.
 Otherwise, there was no any history of dysmenorrhea
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Patient Management Record for

Year 5 Clinical Posting Clerkship

Past gynaecological history

 She had no any gynaecology problem

 No sexually transmitted infections (STIs)
 Not on any contraception method
 PAP smear has not been done
 She claimed that she never experienced post coital bleeding.

Past medical & Surgical history

 She had no underlying medical illness

 There was no surgical intervention done on her before.

Past Drugs & Allergy history

 She was prescribed with obimin once a day and was compliance to it.
 She does not consume any other drugs or traditional medications.
 No known drugs and foods allergy.

Past Family History

 She is the eldest of 5 siblings

 All are healthy except for her father who had hypertension.
 Otherwise, there is no family history of malignancy, multiple pregnancy and bleeding
disorder.

Past Social History

 She was married for 1 year.

 She works as a Specialist Opthalmology Doctor in Hospital Shah Alam while her
husband is a Public Health specialist
 She is non smoker and also non alcoholic drinker
 She claimed that monthly income was adequate.
 They lived in an apartment house at seksyen 7 with her husband.
 She having normal sleep habit.
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Patient Management Record for

Year 5 Clinical Posting Clerkship

PHYSICAL EXAMINATION:

General
Examination

Blood pressure : 109/62 mmHg Pulse rate : 60 /min

Respiratory rate : 20 breath/min Body temperature : 36.9 0 C
Body weight : 59 kg Height : 167 cm

General Inspection

 Patient was lying comfortably in supine position supported by one pillow

 She was small built, well-nourished and hydrated
 She was alert, conscious and well-oriented to time, place and person
 She was not in pain or in respiratory distress.
 ID tag was attached to her right wrist.

Head to toe examination

 Hands
- Warm & Dry to touch
- Capillary refill time is less than 2 seconds
- No peripheral cyanosis, clubbing, koilonychia, leukonychia and palmar
erythema noted.

 Face
- No chloasma

 Eyes
- No subconjunctival pallor
- No jaundice

 Mouth
- Moist oral mucosa
- No angular stomatitis, glossitis or central cyanosis
- Tongue not coated

 Neck
- No neck swelling or lymphadenopathy

 Legs
- No pitting edema or varicose veins
- No calf muscle tenderness
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Patient Management Record for

Year 5 Clinical Posting Clerkship

Systemic Examination:
Cardiovascular Examination

 S1 and S2 were heard on all 4 cardiac region

 No murmur or added sound was heard

Respiratory Examination

 Vesicular breath sound was heard on both lungs.

 There was no added sound heard.

Abdominal Examination

 The abdomen was flat

 Flanks were not full
 Abdomen moves with respiration
 Umbilicus was centrally located and inverted
 No surgical scars and dilated veins
 Hernial orifices were intact.
 On superficial palpation, abdomen was soft and non-tender
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Patient Management Record for
Year 5 Clinical Posting Clerkship

Summary of physical examination:

front

back
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Patient Management Record for
Year 5 Clinical Posting Clerkship

Provisional diagnosis:

Moderate Nausea and Vomiting with Urinary Tract Infection (UTI)

INVESTIGATIONS ORDERED:

1. Full Blood Count

2. Serum Electrolyte
3. Urine analysis
4. ECG

MANAGEMENT PLAN:

1. IV Ranitidine 50mg tds

2. Off iv drip
3. Input Output charting
4. Repeat serum potassium
5. Encourage orally
6. Kiv discharge.

NUR BATRISYIA HUSNA BINTI ZAINURIN

__________________________ ________________________
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Patient Management Record for
Year 5 Clinical Posting Clerkship

Name of medical student Signature

Date: 8/2/2022

Time: 5pm

Discipline: Obstetric & Gynaecology

 2018/2019

Patient Management Record for

Year 5 Clinical Posting Clerkship

PROGRESS NOTES
Date & Time Name & Signature

09/02/2022 – 12.24am
S - Patient resting on bed

O - Vital signs taken and recorded at 2235H

o T : 36.90 C (Afebrile)
o BP : 109/62 mmHg
o HR : 60/bpm
o RR : 20/min
o MFS : 20
o Pain score : 0
o SPO2 : 99%
o Urine ketone : Negative

A - No new complication

P - IV Ranitidine 50mg tds

- Off iv drip
- Input Output charting
- Repeat serum potassium
- Encourage orally
- Kiv discharge.

09/02/2022 – 1.13pm
S - Patient resting on bed

O - Vital signs taken and recorded at 2235H

o T : 36.90 C (Afebrile)
o BP : 109/62 mmHg
o HR : 60/bpm
o RR : 20/min
o MFS : 20
o Pain score : 0
o SPO2 : 99%
o Urine ketone : Negative

A - No new complication

P - Allow discharge with maxolon

- To come again 3 weeks O&G clinic
- Call KK Seksyen 7 next to come again to trace ix result.
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Patient Management Record for

Year 5 Clinical Posting Clerkship

PATIENT DISCHARGE SUMMARY FORM

PATIENT DETAILS:

NAME : AISYAH AMIRAH AGE : 32

SEX : FEMALE RN : CONTACT NUMBER :
ADDRESS :
DATE AND TIME OF ADMISSION : 08/02/2022 , 5am
DATE AND TIME OF DISCHARGE : 09/02/2022 , 1.14pm
WARD / DISCIPLINE : 8A , Obstetric & Gynaecology

CLINICAL SUMMARY:

Madam Aisyah, 32 years old, primigravida at 10 weeks 2 days period of gestation was admitted to
Hospital Shah Alam for moderate nausea and vomiting with Urinary Tract Infection.

On examination, patient’s vital signs were all normal and small build. Otherwise, there is no any
significant findings in Madam Aisyah.

DIAGNOSIS (upon discharge): Moderate Nausea and Vomiting with Urinary Tract Infection

IN-PATIENT MANAGEMENT PROVIDED:

Ix: Mx:
5. Full Blood Count 1. Input Output charting
6. Serum Electrolyte 2. Repeat serum potassium
7. Urinanalysis 3. Encourage orally
8. ECG
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Patient Management Record for

Year 5 Clinical Posting Clerkship

DISCHARGE PLAN:

1. Allow discharge with maxolon, thiamine (2/52)

2. To come again 3 weeks O&G clinic – 3/3/2022.
3. Call KK Seksyen 7 next to come again to trace investigation result.
4. To come again immediately if persistent vomiting.
5. MC until Friday (11/2/2022)

NUR BATRISYIA HUSNA

Name of BINTI ZAINURIN Date prepared: 09/02/2022
Medical Student
Signature Date / Time:
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Patient Management Record for

Year 5 Clinical Posting Clerkship

MEDICATION RECORD FORM

Patient’s name: Hospital: Hospital Shah Alam Date of Admission:

Aisyah Amirah Mohd Zahari 08/02/2022
Ward: 8A
Patient’s body weight: 59 Kg Registration No.:
Medication (dose, route and Medication Please initial on the respective column after
frequency) prescriber: administering the medication
Doctor’s name / Time 9/2
Signature /
Date
Tablet Metoclopramide HCI 1PM
10mg TDS

Tablet Thiamine Mononitrate 1PM

10mg OD
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Patient Management Record for

Year 5 Clinical Posting Clerkship

REFLECTION FORM – LEARNING FROM PATIENT

This form shall be attached to your Patient Management Record that you would like to be
assessed.

INSTRUCTION:

A. LEARNING ISSUES
State ONE (1) your learning issue “What I’ve learnt from this experience”? based on this
case record as examples;
- Case evaluation or diagnostic tools
- Associated complications
- Management which may include pharmacology, therapeutic procedures,
rehabilitation

B. DISCUSSION
Discuss or elaborate further on your learning issue.
(“Answers to my own questions”).
Please include any relevant clinical literatures to support evidence in your discussion.
Note:
- Not more than 500 words. Use of word processer is encouraged (1 page, font
size 12)]
- Must write in your own words, no cut & paste as this is considered plagiarism.

C. REFERENCES
List your references on the literatures that were used in the discussion.
(“Materials/articles that I’ve used to answers to my own questions”)

PATIENT PARTICULARS:

Name: AISYAH AMIRAH MOHD ZAHARI

RN:

Diagnosis: Moderate Nausea and Vomiting with Urinary Tract Infection

Date of admission: 08/02/2022

A. LEARNING ISSUE STATEMENT:

- Learn how to take a full history from a patient with Nausea and Vomiting in pregnancy
and asked more regarding her symptoms.

- I can get the opportunity to do a full examination on the patient. So it may help to brush
up my soft skills
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Patient Management Record for

Year 5 Clinical Posting Clerkship

DISCUSSIONS:

1. Pregnancy Unique – Qualification of Emesis (PUQE) score

 My patient score is 11 and it’s in the moderate stage.

 Etiology :
o Hormonal
- Higher HCG level – twins
- Higer estrogen level
- Progesterone excess – relaxation of cardiac sphincter and impaired gastric motility
o Dietary deficiency – low carbohydrate intake, Vit B6, B1 deficiency
o Psychogenic
o Genetic
o Allergic or immunological basis
o Liver dysfunction
o Vestibular system dysfunction

- So, on my patient case, she had a dietary deficiency which is low in carbohydrate,
Vit B6 and B1
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Patient Management Record for

Year 5 Clinical Posting Clerkship

 Clinical features:
 History
o Nausea
o Vomiting
o Retching
o Features of dehydration
o Sunken eyes
o Dry coated tongue
o Fruity breath smell
o Tachycardia
o Hypotension
o Low appetite
o Reduced urine output
o Jaundice

- My patient had nausea, vomiting, retching, low appetite and reduced urine output

B. REFERENCES:

1. Ten Teachers, 19th edition.