You are on page 1of 1

HOSPITAL QUEEN ELIZABETH II

KOTA KINABALU

CONFIDENTIAL REPORT: ANTENATAL CASE

DOA & Sex &


NO WARD NAME DIAGNOSIS STATUS OF CONDITION REMARK
TIME Age
AERNISAH BIN LOUIS
Patient elective admission to ward for Op. Left
1 FSW 28/05/2017 IC: 970327-12-5698 F/ 20 YRS / Thyroid Ca. Thyroidectomy on 29/5/2017.
Kadazan Patient walking case escorted by his husband.
@09.22PM LMP : 28/3/2017 Plan for elective Patient looking stable and comfortable.
POG :BY SCAN 4/52 Operation on
29/5/2017 for Left GA assessment done and noted no menses for 3
G2P1
Thyroidectomy. month .
-Unbook case UPT was checked and noted Positive before x-ray
at 5.15 PM.
Address:Kg Brunei ,
dekat dengan 1B ,
On examination patient alert , good pulse volume
Kota Kinabalu. and pink.
- Awaitng O&G team to review CM before
Operation.

Vital sign noted


BP : 103/66mmHg
PR: 93/min
Temp :36.8C
RR : 20/min SPO2: 100% on air
Pain Score: 0

Otherwise patient resting in bed with condition


conscious.
-JT Nurul Ashikin (FSW) noted that case and will be
inform to KKIA nearest from address patient coming
morning.

DATE: 28/05/2017(2PM-9PM)
DISEDIAKAN OLEH DISAHKAN OLEH

KJ SITI HUSNI BINTI ENTOH MATRON ISAH SASTRO


(ONCALL 2PM -9PM) (MATRON ONCALL)

HQE 2 HQE 2

You might also like