REKOD IBU

Nama Ibu : Norhasrina Binti Laisam

Kumpulan etnik : Bajau
Umur : 25 Tahun
Warganegara : Malaysia (970126-12-5886)
Tahap Pendidikan : Tingkatan 4
Pekerjaan : Suri rumahtangga
Alamat : Kg. Parapat Laut, Kudat
Nama Suami : Azlan Bin Allan
Kumpulan etnik : Ubian
Warganegara : Malaysia (961126-12-6497)
Pekerjaan : Kerja Sendiri
Tarikh Perkahwinan : 05.07.2018
 REKOD KESIHATAN IBU
• Ibu datang ke KD.Milau untuk booking pada 09.05.2022 (POG : 18/52)
• Faktor risiko : Kod Kuning
1) Poor spacing - LCB 2021
2) GDM on T.Metformin 500mg BD
3) H/O Fetal anomaly in 2021 - 2nd child
Noted child having right unilateral complete cleft lip and palate with left
undescended testis,micropenis & bilateral constricted ears
4) H/O Perinatal Death @ 22/7 due to aspiration pneumonia - 2nd child in 2021
5) Anemia with u/l HbE homozygous
6) Bronchial asthma on MDI Salbutamol 2P PRN

THA(LMP) : 03/01/2022
TAL (EDD) : 10/10//2022
G3 P2
 PERIHAL KANDUNGAN LALU
BI TAHUN HASIL JENIS TEMPAT & JANTINA BERAT KOMPLIKASI PENYUSUAN KEADAAN
L KANDUNGAN KELAHIRAN DISAMBUT LAHIR SUSU IBU ANAK
SEKARANG
(KG)

1 2019 Cukup Bulan SVD Hospital Kudat P 2.9 Tiada 5/12 Hidup sihat
By SN

2 2021 Cukup Bulan SVD Hospital Kudat L 3.29 Right - Meninggal

(POG : By SN unilateral pada umur 22
39/52+6/7) complete hari sebab
cleft lip and aspiration
palate with pneumonia
left
undescended
testis ,
micropenis &
bilateral
constricted
ears
 UJIAN SARINGAN ANTENATAL
BIL JENIS UJIAN TARIKH DIAMBIL KEPUTUSAN

1 KUMPULAN DARAH RHESUS 13/05/2022 O + ve

2 VDRL +/- TPHA 13/05/2022 Negative

3 HIV/RAPIDTEST 09/05/2022 Non Reactive

4 HEPATITIS B 13/05/2022 Non reactive

5 TALASEMIA 2019 Pembawa

talasemia
6 BFMP 13/05/2022 No malaria
parasite seen
 RIWAYAT KESIHATAN IBU DAN KELUARGA
PERIHAL IBU
• Haid : Jumlah hari = 3 - 4 hari
• Pusingan = Tetap
• Tidak merokok
• Masalah perubatan ibu : Asthma dan alergi makanan laut

MASALAH PERUBATAN KELUARGA

- Ibu klien ada Hipertensi dan Sakit Jantung sedang dalam
rawatan
 SESI KLINIK
UJIAN MAKMAL PEMERIKSAAN KANDUNGAN JANIN
TARIKH LK/LR
URIN URIN HB WT BP PULSE EDEMA TEMPOH FH(CM) KEDUDUKAN JANTUNG GERAK
ALB SUGAR (kg) HAMIL PRESENTASI

Lt : 93/58
09/05/2022 mmhg
LK neg neg 9.7 61.5 78 -/- 18/52 19cm Ketulan - -
@ 10.25 am Rt : 94/65
mmhg

23/05/2022 LK neg neg 9.8 63 95/60 82 -/- 20/52 22cm Ketulan - -

@ 8.40 am

15/06/2022
@ 12.00 pm LK neg neg 10.0 64 100/67 81 -/- 23/52 + 2/7 24cm Ketulan 140 bpm +

27/06/2022
@ 11.35 am LK neg neg 9.5 65 107/76 66 -/- 25/52 25cm Cephalic 152 bpm +
 LAWATAN RUMAH
UJIAN MAKMAL PEMERIKSAAN KANDUNGAN JANIN
TARIKH LK/LR
URIN URIN HB WT BP PULSE EDEMA TEMPOH FH(CM) KEDUDUKAN JANTUNG GERAK
ALB SUGAR (kg) HAMIL PRESENTASI

25/05/2022 LR neg neg - - 90/60 105 -/- 20/52 + 4/7 22cm Ketulan 140/min +
@ 8.30am mmhg

06/06/2022 LR neg neg - - 100/60 90 -/- 22/52 + 1/7 22cm ketulan 140/min +
mmhg
 TCA/RUJUK MO/MFM /O&G SPECIALIST
TARIKH DIRUJUK CATATAN
19/05/22 Refer MO for Antenatally :
1st RME and 1. Poor spacing - LCB 2021
19/52 + 3/7 booking 2. H/O GDM on Diet Control
(POA) 3. H/O Perinatal Death @ 22/7 due to aspiration pneumonia - 2nd child in 2021
4. H/O Fetal anomaly in 2021 - 2nd child
Noted child having right unilateral complete cleft lip and palate with left
undescended testis,micropenis & bilateral constricted ears
5. Anemia with u/l HbE homozygous
- Husband : Normal
C/o
No fever
No SOB/palpitation
No Pv Bleeding/discharge
No UTI/URTI
No IE Sx

O/E
No breast lump palpable
Lungs clear
CVS DRNM
No murmur
P/a SNT
TARIKH DIRUJUK CATATAN
TAS
-Singleton/cephalic/FH +
-Placenta Fundal
-Liquor Adeq
-AFI 14.49
-BPD 4.46 ( 20w+0d)
-HC 16.51 (19w+2d)
-FL 3.13 (19w+3d)
-AC 14.09 (19w+3d)
-EFW 300gm

PLAN
- Rescan 2/52 to comfirm date (2.6.22)
- Continue hematinic
- To get date for detail scan once date confirm - KIV refer O&G
- For MOGTT on Monday (23.05.2022)
- Tca stat if PV bleeding/discharge/Abdominal pain
 TARIKH DIRUJUK CATATAN

23/05/22 Refer MO MOGTT : 5.3/8.2

via
20/52 (POA) whatsapp Plan
to review 1. BSP this week
result 2. Strict diabetic diet
MOGTT

24/05/22 Ibu datang Diagnosis : ? Asthma In Pregnancy

mendapatka
20/52 + 1/7 n rawatan di Discharge with
(POA) Jabatan - MDI Salbutamol 2P PRN
Kecemasan - T.Loratidine 10mg OD
Hospital
Kudat Plan
1. TCA ↓ KK.Narandang on 26.5.2022 to Rv Symptom
TARIKH DIRUJUK CATATAN
25/05/22 TCA/RUJUK
Antenatally : MO/MFM /O&G SPECIALIST
Refer MO for
Rescan 2/52 to
1. Poor spacing - LCB 2021
20/52 + 2/7 confirm date 2. GDM on Diet Control
(POA) 3. H/O Perinatal Death @ 22/7 due to aspiration pneumonia - 2nd child in 2021
4. H/O Fetal anomaly in 2021 - 2nd child
Noted child having right unilateral complete cleft lip and palate with left
undescended testis,micropenis & bilateral constricted ears
5. Anemia with u/l HbE homozygous
- Husband : Normal
6. H/O asthma attack - 24.05.2022

C/o
No fever
No SOB/palpitation
No Pv Bleeding/discharge
No UTI/URTI

O/E
Lungs clear
CVS DRNM
P/a SNT
TARIKH DIRUJUK CATATAN
TAS
-Singleton/cephalic/FH +
-Placenta Ant Upper segment
-Liquor Adeq
-AFI 6.40
-BPD 4.80 ( 20w+4d)
-HC 17.13 (19w+5d)
-FL 3.28 (20w+0d)
-AC 14.81 (20w+1d)
-EFW 334gm

PLAN
- Follow Date 10.10.2022
- Rescan 28/52 (21.7.2022)
- Continue hematinic
- Advice for hospital delivery
- To refer O&G for detailed scan,KIV T.MTF 500mg (awaiting input)
- TCA stat if PV bleeding/discharge/asthma attact/sign & sx of labour
 TARIKH DIRUJUK CATATAN

26/05/22 Refer MO BSP (25.5.22) : 5.9/5.5/6.2/6.5

via
20/52 + 3/7 whatsapp
(POA) to review Plan
result BSP 1. Repeat BSP 2/52
2. Strict diabetic diet

10/06/22 Refer MO BSP (9.6.2022) : 5.3/6.8/6.0/7.5

via
22/52 + 5/7 whatsapp Plan
(POA) to review 1. Start T.Metformin 500mg BD
result BSP 2. Repeat BSP 1/52 (16.6.22)
3. Strict diabetic diet
 TARIKH DIRUJUK CATATAN

17/06/22 Refer MO BSP (16.6.22) : 4.6/4.8/5.9/4.9

via
23/52 + 5/7 whatsapp
(POA) to review Plan
result BSP 1. Repeat BSP 1/12 (14.7.2022)
2. Strict diabetic diet
3. Iron study next week (taken @ 22.6.2022 ↓ KK.Sikuati)
17/06/22 @ MO refer Case & progress updated to Dr Michael (MFM)
8.00 am case to - to show scan image to O&G SP
MFM
23/52 + 5/7 Case D/W DR.Maliza
(POA) - TCA today (17.6.2022) ↓ visiting O&G clinic
TARIKH DIRUJUK CATATAN
17/06/22 TCA/RUJUK
Antenatally : MO/MFM /O&G SPECIALIST
O&G visiting
Hospital Kudat
1. GDM on T.Metformin 500mg BD
23/52 + 4/7 S/B 2. H/O Perinatal Death @ 22/7 due to aspiration pneumonia - 2nd child in 2021
(POA) Dr.Normaliza Noted child having right unilateral complete cleft lip and palate with left
undescended testis,micropenis & bilateral constricted ears
BP : 105/68 3. Anemia with underlying HbE homozygous
mmhg - Husband : Normal
PR : 90/min 4. Bronchial asthma
- On MDI Salbutamol 11/11 PRN

C/o
No SOB/No chest pain
No abdominal pain
No Pv Bleeding

O/E
Lungs clear
CVS DRNM
P/a Soft,uterus 22w
TARIKH DIRUJUK CATATAN
TAS
-Singleton
-Placenta Anterior,not low
-BPD 59.6mm ( 24w+2d)
-HC 214.4mm (23w+1d)
-FL 41.9mm (23w+4d)
-AC 184.7mm (22w+6d)
-EFW 604gm (23w+3d)

Detailed scan
Brain : Normal
Spain : Normal
Heart : ? Small VSD seen
Single stomach bubble
Abdominal wall intact
Normal cord

Imp : ? Small VSD

PLAN
- TCA x 2/52 ↓ O&G Clinic HWKKS,for scan By SP (5.7.2022)
- Refer visiting respi for asthma (1.7.2022)
TARIKH DIRUJUK CATATAN
1/07/22 TCA/RUJUK
Respi visiting
Antenatally :
Hospital Kudat
MO/MFM /O&G SPECIALIST
1. GDM on T.Metformin 500mg BD
25/52 + 4/7 2. H/O Perinatal Death @ 22/7 due to aspiration pneumonia - 2nd child in 2021
(POA) Noted child having right unilateral complete cleft lip and palate with left
undescended testis,micropenis & bilateral constricted ears
BP : 106/62 3. Anemia with underlying HbE homozygous
mmhg - Husband : Normal
PR : 85/min 4. Bronchial asthma
Temp : 36.5 - On MDI Salbutamol 11/11 PRN

Asthma during pregnancy

Has alergic to seafood + alergic rhinitis

Has cough during rainy weather/cold

S/T Dr.Irfan (ENT)

- Start Nasonex 11/11 OD

Plan
1. Start Loratidine 10mg OD
2. MDI Budesonide 11/11 BD
3. Refer ENT for Nasonex
4. Cont MDI Salbutamol 11/11 PRN
5. Arrange for combined clinic ↓ HWKKS
TARIKH DIRUJUK CATATAN
5/07/22 TCA/RUJUK
Antenatally : MO/MFM /O&G SPECIALIST
O&G Clinic
1. GDM on T.Metformin 500mg BD
26/52 + 1/7 2. H/O Perinatal Death @ 22/7 due to aspiration pneumonia - 2nd child in 2021
(POA) Noted child having right unilateral complete cleft lip and palate with left
undescended testis,micropenis & bilateral constricted ears
BP : 100/62 3. Anemia with underlying HbE homozygous
mmhg - Husband : Normal
PR : 78/min 4. Bronchial asthma
- On MDI Salbutamol 11/11 PRN

Currantly Pt well
Fetal movement felt
No leaking liqour/PV bleeding

TAS
-Singleton
-Placenta Anterior,not low
-DVP 6.4
-EFW 931gm
-Grossly normal fetus obstacles
-No VSD,No cleft palate/lips

PLAN
1. Cont KKIA f/up
 TARIKH DIRUJUK CATATAN

06/07/22 @ MO refer Case & progress updated to Dr Michael (MFM)

10.00 am case to - continue plan O&G HWKKS
MFM - continue KK follow up
26/52 + 2/7
(POA)

8/07/2022 Refer MO Iron 8.1

result Iron UIBC 55.9
26/52 + 4/7 Study TIBC 64.0
(POA) Ttransferritin Saturation 12.7
Ferritin 14.7

Plan
1. T. Ferrous Fumarate 11/11 OD
2. Monitor FBC 2/52

11/07/2022 MO refer Received input from MFM

case to - To put under FMS for her Bronchial Asthma
27/52 (POA) MFM
 UBAT-UBATAN
Hematinik
 Tab.ferrous fumarate 200mg OD
 Tab.Folic acid 1/1 OD
 Tab.Vit C 1/1 OD
 Tab.B Complex 1/1 OD

 Tab.Metformin 500mg BD

MDI Salbutamol 2P PRN

MDI Budesonide 11/11 BD

Nasonex 11/11 OD
 PENDIDIKAN KESIHATAN

1. Kepentingan datang awal ke klinik untuk daftar mengandung

2. Bahaya anemia kepada ibu dan anak
3. Teruskan rawatan mengikut arahan doktor
4. Elakkan buat kerja berat
5. Banyakkan berehat
6. Pemakanan yang tinggi zat besi seperti sayuran hijau, hati ayam dan ikan
7. Pemakanan ibu antenatal GDM
8. Segera ke hospital jika ada sebarang masalah kesihatan atau kandungan
9. Bersalin di hospital
10. Merancang keluarga selepas bersalin
 Perancang Keluarga

• Klien memilih pil untuk merancang keluarga selepas

bersalin