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 trimester Down screening / Second trimester NIPT} revealed low risk for Down syndrome. Amniocentesis {was not performed / was 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. 

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 SA AA E
   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: bain iv.
. Current medication:

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

After admission, cardiotocography was kept. Cesarean section was performed on []. A live premature male 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.