Note

Informant: patient and past medical records
Pregnancy for []+[] weeks, with {previous Cesarean section / fetal malpresentation / placenta previa / previous myomectomy history}, for scheduled Cesarean section

【Present Illness】
This []-year-old, gravida-[] para-[] woman is pregnant for []+[] weeks. She received regular prenatal examination at Dr.[]'s outpatient clinic. {First / Second} trimester {Down screening / NIPT} revealed low risk for Down syndrome. Amniocentesis was {not performed / performed and showed normal karyotype}. Level II sonography did not show major anomaly of the fetus. 

Her blood pressure remained in the normal range during this gestation. OGTT test showed {negative / positive} for gestation diabetes. Group B streptotoccus screening was {negative / positive}.

Reviewing her history, her {first / second} pregnancy was complicated with {prolonged labor / cephalopelvic disproportion / fetal malpresentation / placenta previa}, and Cesarean section delivery was performed on []. Due to previous Cesarean section, she is admitted on [] for scheduled Cesarean section.

Sonography examination at our clinic revealed {singleton / twin} pregnancy with {fetal oblique/transverse/breech malpresentation / placenta previa} on []. Under the impression of {fetal malpresentation / placenta previa}, she is admitted on [] for scheduled Cesarean section.

【Past History】
1. Major systemic diseases: denied
2. Current medication: [], herb(-), supplement(-)
3. Social history: smoking(-), alcohol(-), betel nut(-)
4. Allergy: no known allergy, denied adverse drug reactions
5. Operation history: denied
6. Family history: diabetes(-), hypertension(-), preterm birth(-), major congenital malformation(-)
7. TOCC history: travel(-), cluster(-), contact(-)
8. OBGYN history:
   G P AA SA E (NSD* , C/S* )
   Menarche:  years old
   Menstrual cycle interval/duration: []/[] days 
   Last menstrual period: []
   Estimated date of confinement: []
9. Prenatal examination: 
   Hypertension(-)
   Proteinuria(-)
   Gestational diabetes mellitus(-)
   Hepatitis B screening(-)
   Group B streptotoccus(-)
10. Other prenatal exam finding: 
   Level II sonography: no major anomaly
   Amniocentesis: not performed
   aCGH: not performed
   SMA genetic testing: not performed
   Fragile X genetic testing: not performed
11. Vaccination during pregnancy: denied

1. Systemic: weight loss(-), anorexia(-), night sweats(-), fever(-), dizziness(-), easy-fatigue(-)
2. HEENT: headache(-), neck mass(-), epistaxis(-), oral ulcer(-)
3. Cardiovascular: exertional dyspnea(-), orthopnea(-), syncope(-), palpitation(-), intermittent claudication(-)
4. Respiratory: cough(-), hemoptysis(-)
5. Gastrointestinal: epigastralgia (-), diarrhea (-), abdominal pain(-), abdominal distension(-), constipation(-)
6. Urogenital: urinary frequency(-), urgency(-), dysuria(-), voiding difficulty(-), dysmenorrhea(-), menorrhagia(-)
7. Musculoskeletal: bone pain(-), arthralgia(-)
8. Metabolic: heat intolerance(-), cold intolerance(-), thirsty(-)
9. Nervous: numbness(-), paresis/plegia(-)
10. Skin: rash(-), pruritus(-), dryness(-), jaundice(-), color changes(-)

Others: lower abdominal tightness(-), vaginal bleeding(-), vaginal watery discharge(-)

Neurological Examination: 
. Consciousness: clear
. Muscle power: full 
. Gait: steady

1. Consciousness: clear and oriented.
2. Vital signs: as above.
3. Head, ear, eye, nose and throat: 
(1) Eye: conjunctiva: not pale; sclera: not icteric; light reflex: +/+.
(2) Neck: supple, no lymphadenopathy, no jugular vein engorgement.
4. Neurological exam: 
(1) E4M6V5; cranial nerve examinations: CNII-XII grossly intact. 
(2) Motor systems: muscle power 5/5 throughout, tone within normal limits. 
(3) Sensation: intact to sharp and dull throughout.
(4)  Gait: steady.
5. Chest: symmetric expansion and no deformity, breath sounds: clear.
6. Heart: regular heartbeats, no obvious murmur.
7. Abdomen:
(1) Ovoid, tenderness(-), no rebound tenderness, no shifting dullness.
(2) Bowel sound: normoactive.
(3) Liver and spleen: not palpable.
(4) Previous OP scar: nil.
8. Extremities: mild pitting edema, free range of motion.

Pelvic Examination: Not performed

#. Pregnancy for []+[] weeks, with {previous Cesarean section / fetal malpresentation / placenta previa / previous myomectomy history}, for scheduled Cesarean section

【S】
. Lower abdominal pain(-)
. Watery discharge(-), bloody show(-)
. Fetal movement: as usual, not decreased
【O】
. Vital sign: stable, afebrile, no hypertension
. U/A: proteinuria(-)
. Uterine contraction: 1/[] mins, FHB: category I
【A】
. As above
【P】
. Admission routine and preoperative preparation. 
. Arrange fetal assessment.
. Perform cardiotocography.

Treatment goal:
. Monitor fetal condition via cardiotocography and deliver healthy neonate.
. Post delivery day 5 discharge.

{CS today / POD[]}
. Tolerable wound and contraction pain
. No nausea or vomiting
. Flatus(-), stool passage(-)

. T: [] °C, P: [] bpm, R: [] /min
. BP: []/[] mmHg
. Pain: []/10
. Hb: [] g/dL, WBC [] K/μL

. Special discomfort: uterine contraction pain
. General Appearance: fair
. Uterus contraction: hard
. Lochia: little
. Operation wound: no discharge
. Pain special management: PCA
. Current medication:

. Keep post-partum care
. Encourage early ambulation and breast feeding
. Post-OP wound management on POD1
. May be discharged on POD5

#. Pregnancy for []+[] weeks, with {previous Cesarean section / fetal malpresentation / placenta previa / previous myomectomy history}, for scheduled Cesarean section

#. Pregnancy for []+[] weeks, with {previous Cesarean section / fetal malpresentation / placenta previa / previous myomectomy history}, status post Cesarean section on []

After admission, cardiotocography was kept. Cesarean section was performed on []. A live {mature/premature} {male/female} baby was delivered by vertex extraction at [] with birth weight [] gram and Apgar score [] to []. The postpartum course was uneventful without complication. She was discharged on [] and will receive OPD follow-up.

妊娠[]週，合併[]，剖腹產後

病人因上述疾病，於[]年[]月[]日在本院住院，醫學上建議行剖腹產，於[]年[]月[]日行剖腹生產手術產下一名{男/女}嬰，於[]年[]月[]日出院，宜於門診持續追蹤治療。

Pregnancy for [] weeks, {with regular lower abdominal pain / with a gush of watery vagina discharge / without labor signs for induction}

This []-year-old, gravida-[] para-[] woman is pregnant for []+[] weeks. She received regular prenatal examination at Dr.[]'s outpatient clinic. {First / Second} trimester {Down screening / NIPT} revealed low risk for Down syndrome. Amniocentesis was {not performed / performed and showed normal karyotype}. Level II sonography did not show major anomaly of the fetus. 

Her blood pressure remained in the normal range during this gestation. OGTT test showed {negative / positive} for gestation diabetes. Group B streptotoccus screening was {negative / positive}. The pregnancy course was uneventful throughout the gestation. Neither major anomaly of the fetus nor medical complications of the mother was found in the serial follow-ups at our clinic. 

{Regular lower abdominal pain / a gush of watery vaginal discharge} was noted since [], and she went to our obstetric Emergency Department for evaluation. On arrival, pelvic exam showed cervical dilation [], station [], effacement []. NST showed regular uterine contractions every [] mins and category I FHB with normal baseline and moderate variability. 

Due to {labor signs / rupture of membranes / no labor signs}, she was admitted for {vaginal delivery / induction of labor}.

【Past History】
1. Major systemic diseases: denied
2. Current medication: [], herb(-), supplement(-)
3. Social history: smoking(-), alcohol(-), betel nut(-)
4. Allergy: no known allergy, denied adverse drug reactions
5. Operation history: denied
6. Family history: diabetes(-), hypertension(-), preterm birth(-), major congenital malformation(-)
7. TOCC history: travel(-), cluster(-), contact(-)
8. OBGYN history:
   G P AA SA E (NSD* , C/S* )
   Menarche:  years old
   Menstrual cycle interval/duration: []/[] days 
   Last menstrual period: []
   Estimated date of confinement: []
9. Prenatal examination: 
   Hypertension(-)
   Proteinuria(-)
   Gestational diabetes mellitus(-)
   Hepatitis B screening(-)
   Group B streptotoccus(-)
10. Other prenatal exam finding: 
   Level II sonography: no major anomaly
   Amniocentesis: not performed
   aCGH: not performed
   SMA genetic testing: not performed
   Fragile X genetic testing: not performed
11. Vaccination during pregnancy: denied

1. Systemic: weight loss(-), anorexia(-), night sweats(-), fever(-), dizziness(-), easy-fatigue(-)
2. HEENT: headache(-), neck mass(-), epistaxis(-), oral ulcer(-)
3. Cardiovascular: exertional dyspnea(-), orthopnea(-), syncope(-), palpitation(-), intermittent claudication(-)
4. Respiratory: cough(-), hemoptysis(-)
5. Gastrointestinal: epigastralgia (-), diarrhea (-), abdominal pain(-), abdominal distension(-), constipation(-)
6. Urogenital: urinary frequency(-), urgency(-), dysuria(-), voiding difficulty(-), dysmenorrhea(-), menorrhagia(-)
7. Musculoskeletal: bone pain(-), arthralgia(-)
8. Metabolic: heat intolerance(-), cold intolerance(-), thirsty(-)
9. Nervous: numbness(-), paresis/plegia(-)
10. Skin: rash(-), pruritus(-), dryness(-), jaundice(-), color changes(-)

Others: lower abdominal tightness / vaginal bleeding / vaginal watery discharge: -/-/-

Neurological Examination: 
. Consciousness: clear
. Muscle power: full 
. Gait: steady

1. Consciousness: clear and oriented.
2. Vital signs: as above.
3. Head, ear, eye, nose and throat: 
(1) Eye: conjunctiva: not pale; sclera: not icteric; light reflex: +/+.
(2) Neck: supple, no lymphadenopathy, no jugular vein engorgement.
4. Neurological exam: 
(1) E4M6V5; cranial nerve examinations: CNII-XII grossly intact. 
(2) Motor systems: muscle power 5/5 throughout, tone within normal limits. 
(3) Sensation: intact to sharp and dull throughout.
(4)  Gait: steady.
5. Chest: symmetric expansion and no deformity, breath sounds: clear.
6. Heart: regular heartbeats, no obvious murmur.
7. Abdomen:
(1) Ovoid, tenderness(-), no rebound tenderness, no shifting dullness.
(2) Bowel sound: normoactive.
(3) Liver and spleen: not palpable.
(4) Previous OP scar: nil.
8. Extremities: mild pitting edema, free range of motion.

[Pelvic Examination]
os: close, station: high, effacement: poor

#. Pregnancy for []+[] weeks, {with labor signs / with rupture of membranes / without labor signs}, for {vaginal delivery / induction}

【S】
. Lower abdominal pain(-)
. Watery discharge(-), bloody show(-)
. Fetal movement: as usual, not decreased
【O】
. Vital sign: stable, afebrile, no hypertension
. U/A: proteinuria(-)
. Uterine contraction: 1/[] mins, FHB: category I
【A】
. As above
【P】
. Admission routine and preoperative preparation. 
. Arrange fetal assessment.
. Perform cardiotocography.

Treatment goal:
. Monitor fetal condition via cardiotocography and deliver healthy neonate
. Post delivery day 3 discharge

【Present Illness】 
This is a []-year-old woman, G[]P[]AA[]SA[]E[], with the past history of:

#.
#.

This time, due to [], she was admitted for surgical intervention.

【Past history】
1. Major systemic diseases: diabetes mellitus(-), hypertension(-), others: denied. 
2. Current medication:
   . 
3. Social history: smoking/alcohol/betel nut: denied/denied/denied.
4. Allergy: no known allergy.
   Adverse drug reactions: denied.
5. Operation history:
   . 
6. Family history: diabetes mellitus(-), hypertention(-), uterine myoma(-), breast cancer(-), colon cancer(-), endometrial cancer(-), ovarian cancer(-), others: denied.
7. TOCC history: denied recent traveling, denied cluster or contact history.

【History of Obstetrics and Gynecology】
1. G P AA SA E (NSD* , C/S* ), sexual experience: [], marital status: [].
2. Menarche: [] years old, menopause: nil, hormone therapy: nil, 
   Menstrual cycle: interval/duration: []/[] days,
   Amount: moderate, dysmenorrhea[], last menstrual period: []
3. Last Pap smear and result: [] within normal limits.

系統性回顧(Review of Systems)
1. Systemic: weight loss(-), anorexia(-), night sweats(-), fever(-), dizziness(-), easy-fatigue(-)
2. HEENT: headache(-), neck mass(-), epistaxis(-), oral ulcer(-)
3. Cardiovascular: exertional dyspnea(-), orthopnea(-), syncope(-), palpitation(-), intermittent claudication(-)
4. Respiratory: cough(-), hemoptysis(-)
5. Gastrointestinal: epigastralgia (-), diarrhea (-), abdominal pain(-), abdominal distension(-), constipation(-)
6. Urogenital: urinary frequency(-), urgency(-), dysuria(-), voiding difficulty(-), dysmenorrhea(-), menorrhagia(-)
7. Musculoskeletal: bone pain(-), arthralgia(-)
8. Metabolic: heat intolerance(-), cold intolerance(-), thirsty(-)
9. Nervous: numbness(-), paresis/plegia(-)
10. Skin: rash(-), pruritus(-), dryness(-), jaundice(-), color changes(-)

Neurological Examination: 
. Consciousness: clear
. Muscle power: full 
. Gait: steady

1. Consciousness: clear and oriented.
2. Vital signs: as above.
3. Head, ear, eye, nose and throat: 
(1) Eye: conjunctiva: not pale; sclera: not icteric; light reflex: +/+.
(2) Neck: supple, no lymphadenopathy, no jugular vein engorgement.
4. Neurological exam: 
(1) E4M6V5; cranial nerve examinations: CNII-XII grossly intact. 
(2) Motor systems: muscle power 5/5 throughout, tone within normal limits. 
(3) Sensation: intact to sharp and dull throughout.
(4)  Gait: steady.
5. Chest: symmetric expansion and no deformity, breath sounds: clear.
6. Heart: regular heartbeats, no obvious murmur.
7. Abdomen:
(1) Soft and flat, tenderness(-), no rebound tenderness, no shifting dullness.
(2) Bowel sounds: normoactive.
(3) Liver and spleen: not palpable.
(4) Previous OP scar: ***nil/horizontal C/S scar.
8. Back: no costovertebral angle knocking tenderness. 
9. Extremities: free range of motion, no peripheral edema.

【Pelvic Examination】
(1) Vulva: grossly normal.
(2) Discharge: scanty, whitish.
(3) Vagina: grossly normal.
(4) Cervix: no obvious erosion.
(5) Uterus: Avfl / Rvfl, with normal size / enlarged.
(6) Adnexa: free / indurated.

#.

【S】
. Lower abdominal pain(-)
. Vaginal discharge(-)
【O】
. Vital sign: stable, afebrile, no hypertension
【A】
. As above
【P】
. Arrange operation tomorrow

Treatment goal:
1. Post operative day [] discharge.
2. Prevent post-operative wound infection.

{OP today / POD[]}
. Tolerable wound pain
. Flatus(-), urination(-)

. T: [] °C, P: [] bpm, R: [] /min
. BP: []/[] mmHg
. Pain: []/10
. Hb: [] g/dL, WBC [] K/μL

. General Appearance: fair
. Operation Wound: clean
. Vaginal discharge: no
. Current medication:

. Post-OP wound management on POD2
. Encourage ambulation for GI peristalsis
. Try diet after bowel movement
. May be discharged on POD[]

After admission, pre-operative preparation was completed. [] was performed on []. Operative findings revealed []. The postoperative course was uneventful without complication. She was discharged on [] and will receive OPD follow-up for the pathology report.

病人因上述疾病，於[]年[]月[]日在本院住院，於[]年[]月[]日接受[]手術，於[]年[]月[]日出院，宜於門診持續追蹤治療。