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CASE PRESENTATION
KAARTHIGAN RAMAIAH
016-201204-00011
PERSONAL DATA
• Patient’s Name : Suriah binti Sulaiman
• R/N : 48017
• Age : 32 years old
• Address : Sagil, Ledang
• Marital Status : Married
• Gravida :2
• Para :1
• LMP : 18 July 2015
• EDD : 25 April 2016
• POA : 38 weeks
• Height : 147 cm
• Weight : 94 kg
CHIEF COMPLAINT
• Madam Suriah, 32 years old, gravida 2
para 1 at 38 weeks period of gestation
was admitted to Hospital Pakar
Sultanah Fatimah Muar for elective
lower segment caesarean section due
to macrosomia fetus.
HISTORY OF PRESENTING
ILLNESSES
On 18th April 2016, the patient came to
hospital after being scheduled for elective
lower segment caesarean section on 20th
April 2016 in the afternoon.
At 22 weeks period of gestation during
her booking, she was diagnosed to have
gestational diabetes mellitus after being
tested for modified glucose tolerance test.
She was only advised to control her diet
and was not prescribed any medication.
• The transabdominal ultrasound
revealed a macrosomic baby with
estimated fetal weight of 4.2 kg during
her follow up. She was advised for
elective lower segment caesarean
section.
MENSTRUAL HISTORY
• She attained menarche at the age of
12 years old with regular cycle of 28
days, lasting for 5-7 days of bleeding.
The amount was about 2-3 pads fully-
soaked. No clots. No dysmenorrhea.
PRESENT OBSTETRICAL HISTORY
• The patient did a self-urine pregnancy
test brought from the pharmacy and it
came out positive. Subsequently, she
went to a nearest clinic to reconfirm
and the result was consistent. Early
ultrasound scan was done and
confirmed her pregnancy at 14 weeks
period of gestation.
• At 22 weeks, period of gestation, she went to
hospital for booking. Routine examination and
screening was done. All were all within normal
range. She was also screened for Gestational
Diabetes Mellitus by testing the modified glucose
tolerance test Results were as follows:
2-hour
8.3 mmol/L
postpandrial
• She was diagnosed of having gestational diabetes
mellitus and was advised on diet control. No
medications were prescribed. Her blood sugar
profile was controlled throughout the pregnancy.
Her latest blood sugar profile (BSP) on admission
was normal:
2-hour
4.5 mmol/L
postpandrial
PAST GYNAECOLOGICAL
HISTORY
• She had pap smear done in 2012 and there were no
abnormalities detected.
CONTRACEPTIVE HISTORY
• The patient denied usage of any contraceptive pills
or other method.
Face
No pallor, no cyanosis, no jaundice
Mouth
Oral hygiene is good, no sublingual jaundice, no central cyanosis
Neck
No visible enlargement of thyroid, no visible enlargement of lymph
node
Hand
No koilonychia, no leuconychia, no peripheral cyanosis, no pallor, no
finger clubbing. Pulse is 86 bpm, BP is 128/56 mmHg
Chest
Both breasts were symmetrical, nipples were everted, no
visible discharge from the nipples, no ulcers around the
breast region and no visible enlargement of axillary lymph
node.
Abdomen
Abdomen is distended, linea nigra seen, striae gravidarum
seen, umbilicus is everted, no previous surgery scars.
Legs
No swelling, no varicosity, No bilateral pitting ankle edema
B) PALPATION
• Results: Reactive.
• Interpretation: Fetal not in distress.
4. Full Blood Count
Component Results Ref. range Status
BP 124/72 mmHg
Pulse Rate 92/min
Respiratory Rate 18 breaths/min
SpO2 99%
• Bromage Score
• Pain Score
0/10
• Post Anaesthesia Recovery Score
4 CONCIOUSNESS Arousable 1
5 COLOUR Pink 1
Total 6/6
• Acute pain Survey (APS)
Operation Lower Section Caesarean Section
Anaesthesia Epidural
Epidural Catheter inserted Skin to space : 5cm
In space : 5cm
MANAGEMENT
IV Augmentin 1.2g TDS
Analgesia as per APS round
Heavy Marcaine 0.5%
Strict pad chart
Strict I/O chart