HISTORYName: PuziyahRegistration number: (Ward 9C, Bed 18)Age: 52 years oldGender: FemaleRace : MalayReligion: IslamOccupation: Fulltime housewifeAddress: Marital status: Married since 2006Parity/Abortions : P5Date of Admission: 17th November 2014Date of Clerking: 18th November 2014

CHIEF COMPLAINT She is readmitted in Gynaecology ward 9C of Hospital Sungai Buloh (HSB) for her Hysteroscopy and possible Oophorectomy. HISTORY OF PRESENT ILLNESSMy patient, Madam Puziyah, a 52 year Malay housewife with Para 5 is readmitted for further investigation on her ovarian mass. Over than a month back, she is admitted in the same ward due to abdominal pain that radiates to the back for 1 day. The pain is characterized as a slow rising dull pain which was bearable, over the abdominal regions, radiating towards the back, coming intermittently, aggravated by movements, relieved by resting. She also complained of amenorrhea for 4 months but upon admission, she complained of bleeding for 4 days. It was brown in colour, characterized as thick discharge, no clots, and no smell with no pain. She changes 2 pads every day and it stops after 4 days. She complaint of having bleeding again after 2-3 weeks prior to her last bleeding. She changes 3 pads a day this time as the discharge was watery this time, changing from thick brown to bloody red in the period of 4 days. She did not complain of any period like symptoms with no smell was noted.

HISTORY OF PRESENT PREGNANCYThis was an unplanned pregnancy. My patient for to Klinik Kesihatan Bandar Botanik after having persistent cough for over 2 months. During enquiries, she also complained on missing her period by 2 weeks, the doctor did a urine pregnancy test (UPT) and the results obtained was positive. Her cough later recovered by taking Benadryl for around 2 weeks. Her booking date was on the 16th week of pregnancy, done together with her dating scan confirming her pregnancy with an alive, singleton foetus, giving a revised expected date of delivery (REDD) of 9th November 2014. Her weight and height at the time of booking was 72.5kg and 162cm, respectively, giving a body mass index (BMI) of 27.63 which proves that she is slightly overweight. A number of test were done, her blood group is A-positive. She underwent various blood tests, urine full examination microscopic examination (uFEME), and screening tests for syphilis, hepatitis B and HIV. Urine test results were normal with no bacteriuria, ketonuria, and proteinuria. She has not done any MOGTT test till date even with risk factors of being overweight and age above 25 years old. She had persistent cough with sputum for 2 months which she recovers after treatment of Benadryl. She had morning sickness throughout the pregnancy, persisting till today. No bleeding occurred.On second trimester, patient had experienced quickening on 17th week of period of gestation. Her weight increase to 77kg. She had done her ultrasonography scan on Jun, giving results of no nuchal translucency, no congenital anomalies and foetal age is corresponding to the weeks of gestations together with no other uterine or foetal malformation seen in the ultrasonography. Her uterine size is corresponding to the period of gestation. She was diagnosed on having low haemoglobin level at week 19 and was prescribed with Obimin and Iron tablet suggestive of Ferous Fumerate. No MOGTT done and her BP was recorded as normal. She had received an injection of Tetanus Toxoid in late 6 months of period of gestation. She was advised on a diet control to increase her haemoglobin level.Her haemoglobin level resolved after 6 weeks under treatment. Her current weight is 81kg. Her foetal movement has been normal ever since, having more than 10 kicks every 12 hours. She just undergone her ultrasonography yesterday, showing normal growth of the foetus without any anomalies of organs and skeletal deformities. AFI was in the normal range (14) and liquor amnii is adequate ( in 39th week) . No abnormalities detected in her placenta. Her uterine size is corresponding to the week of gestation.

GYearPregnancyLabour PuerperiumBabyRemarks

115/9/2006Full termSpontaneous vaginal delivery (SVD)

No complicationsGirl, 3.0kg, alive,No complications, healthyBreastfeed for 1 year, stop because conceiving second child

27/3/2008Full term Lower segment caesarean section (LSCS)No complicationsBoy, 3.4kg, alive, fetal distress , currently healthyBreastfeed for 3 months, stop due to baby having heart problem, given formulated milk in hospital and then doesnt want to drink anymore after discharge.

32010 Spontaneous miscarriage at 8th weeks of of gestation, Dilatation and Curettage not done.

46/12/ 201040 weeks 4 daysSVDNo complicationsBoy, 3.3kg, alive, no complications, healthyBreastfeed for 2 and half years

52014Current pregnancy

PAST OBSTETRICS HISTORY

MENSTRUAL HISTORYMadam Azly first attain her period (menarche) was on 13 years of age, having a regular cycle of 28 days. The duration of period was seven days and the heaviest blood flow usually occurred on the second and third day of menstruation, where she had to change sanitary pads three to four times a day. Her menstrual cycle was regular for the past three months prior to her last menstrual period. For every menstruation, she had no dysmenorrhoea and no menorrhagia. She have taken oral contraceptive pills after the birth of her second child for 3 to 4 months and stop taking it without any reasons. The OCP she was taking was Mercilon.

GYNAECOLOGICAL HISTORYMadam Azly has never done Pap smear test before. She has no history of sexual transmitted infections before, not having bleeding after having intercourse with her husband. She does not have any gynaecological history.

PAST MEDICAL HISTORYMy patient is healthy throughout her life with no past medical intervention such as Hypertension diseases, Diabetes Mellitus, Asthma, Hyperthyroidism/Hypothyroidism or Tuberculosis.

PAST SURGICAL HISTORYMadam Azly has only undergone surgery (LSCS) for her second pregnancy, other than that, no significant surgical history such as appendectomy, laparoscopic surgery for infertility, thyroidectomy or cholecystectomy has been done.

FAMILY HISTORYPatient is the eldest among the 5 siblings, all her siblings are healthy with no known medical conditions. Her mother, 55 years old lady, who is currently taking care of her children, and her father, a 55 year old man are alive with no known medical conditions.

PERSONAL HISTORYPatient is a non-smoker, non-alcoholic and not a drug abuser. She is not allergic to any type of food or medications. She is a non-vegetarian, having 5-6 meals per day. She has enough rest every night together with 1-2hours nap every evening. She do not complain of having constipation and her micturition is normal. She has not taken any traditional medications before this. SOCIAL HISTORYNor Azly has been married for 8 years. Her husband works as a welder. She and her husband share a good relationship. Her husbands, Asrun do smokes but does it outside of the house, or away from her, preventing to develop any type of complications both to the mother and the baby. Her husband works as a contractor. Their basic needs are fulfilled.

DRUG HISTORYPatient has no significant history of drug and food allergy. She has not taken any supplementary drugs other than Obimin and iron supplement and Benadryl during her pregnancy.

PHYSICAL EXAMINATION

GENERAL EXAMINATION On the day of clerking, the patient was well, conscious, well-orientated with time, very co-operative and was sitting on her bed. She has a large built and well nourished. She was having regular contraction causing her to be less comfortable. Her body mass index was (BMI) was 30.86 kg/m2

At the time, the patients body temperature was normal (37C) and her pulse rate was 90 beats per minute. Her blood pressure was recorded in left lateral position, the reading was 126/70mmHg.

A. VITAL PARAMETERS Temperature = 37C Blood pressure = 126/72mmHg Pulse rate = 90 beats per minute Respiratory rate = 14 per minuteB. HEAD AND NECK. No puffiness Chloasma detected Conjunctiva was pink Sclera was white, no icterus detected, no indication of jaundice. No central cyanosis. No angular stomatitis and glossitis. No bleeding in gums or gum hypertrophy observed. Oral hygiene is good No thyroid enlargement. JVP was not raised.

C. HAND Palm was warm and dry. There was no pallor. Capillary filling time was adequate. (