UNIVERSITI KEBANGSAAN MALAYSIA

LONG CASE WRITE UP

Module : OBSTETRICS & GYNAECOLOGY


STUDENT NAME: MUHAMMAD KHAIRI AMMAR BIN MOHD SIDEK
MATRIC NO : YEAR/GROUP :
SUPERVISOR :DR.WAGIH

ASSESSMENT OF CASE WRITE-UP:
Core Clinical Component
History /10 Critical Appraisal /5
Physical Examination /10 Discharge Summary }
Investigation /5 Referral Letter } /5
Diagnosis/ Differential Diagnosis /5 Prescription }
Identify Problems, management and
progress of patient
/5 References /5
Total Score
MARKS FOR CORE CLINICAL COMPONENT
Professionalism Component
PART 1 : Issue on Professionalism /10
PART 2 : Reflection & Life Long Learning /10
Total Score
MARKS FOR PROFESSIONALISM COMPONENT
M000311 3 4
/50
/20

Patient name : Farah Salwani
Age : 27 years old
I/C number : 861108075148
Register number : 23420/13
Gender : Female
Race : Malay
Date of admission : 26
th
November 2011
Date of clerking : 27
th
November 2011

CHIEF COMPLAINT
Puan Farah Salwani is a 27 years old Malay teacher, primid gravida,, her last menstrual
period (LMP) was on 10
th
April 2013. Currently, her period of amenorrhea is at 34 week of
gestation, thus, her expected date of delivery is on 17
th
January 2014 which correspond to the
date. She was admitted in the ward due to placenta previa type 4.
HISTORY OF PRESENTING ILLNESS
She was last well 1 and half month ago (28
th
weeks of POA) when she noticed there was
vaginal bleeding while getting dress. It was reddish brown in color, dribbling in nature and not
associated with pain. The amount was small and it frequently occurs on that day. The patient felt
uncomfortable and change her pad regularly. She denied of having fever, headache, nausea, and
vomiting. There was no history of urinary tract infection as the patient claimed that she did not
has difficulty in passing urine, no nocturia, no frequency and urgency. The urine color was
normal and no haematuria. However at that time the patient did not seek for any medication.
Unfortunately, the amount of bleeding was increased on the next day. Hence, she went to the
private hospital in Taiping. At the casualty, CTG and ultrasound was done to monitor the baby
condition, there was no abnormality to the fetus. However, the patient was told by a doctor that
she has a low-lying placenta. So she stayed on that hospital for 2 days to monitor her condition.
2 weeks later, she was referred to Hospital Kulim and went to the clinic pakar 2. At that time,
again the scan was done, she was diagnosed to has placenta previa type 3. Her last scan was on
28
th
November which is 2 days after the admission, at that time the scan shown it was placenta
previa type 4. Her current condition is well and no contraction pain indicated. There was no per
vaginal bleed noted and no symptom of anemia. Her hemoglobin level was 11.8. She also was
diagnosed to have gestational diabetes which in diet control, however she did not remember her
blood sugar profile result. This patient also has completed IM dexamethasone for fetus lung
maturation.
This is unplanned and wanted pregnancy. She knew that she was pregnant when she
missed her period at 8 weeks of gestation and urine pregnancy test (UPT) was done by herself at
home which tested positive. On the next day, she went to the private clinic and scan was done.
She was told that her baby was growing well. There was a singleton fetus in longitudinal lie with
cephalic presentation. The liquor was adequate and the placenta located at upper segment of the
uterus. The pregnancy had progress well.
4 weeks later, she had her first booking at 12 week of gestation at the Klinik Kesihatan
Tanjung Rambutan. At this visit, she was told that her hemoglobin level was low and anaemic.
She was normotensive and no glycosuria or proteinuria. Her weighed was 62 kg. Her blood
group is O positive and infectious screening test was normal. She was prescribed with
haematinic Obimin and Iberet. Both medications were taken once daily. However, she has stop
Obimin after 2 months. No scan was done during first booking. She had regular antenatal
checkup at government clinic and no excessive weight gain was noted. After 2 weeks, she went
to the same clinic for follow up of her hemoglobin level. At that time, MOGTT was done as the
patient has a strong family history with diabetes. She was also diagnosed to have gestational
diabetes mellitus. Hence, she was advised by a doctor to be in diet control. She had several
antenatal checkups for 4 times and her anemia was resolved after 2 months. She had several
ultrasound performed and the last scan was done yesterday She had quickening at the 21 week of
gestation.



GYNAE HISTORY
She attained menarche at the age of 13. Her menses was regular in 28 days. The flow
was minimal for 6-8 days and not associated with dysmenorrheal. She never had a pap smear
done before.
PAST OBSTETRIC HISTORY
NIL
CONTRACEPTIVE HISTORY
NIL
PAST MEDICAL AND SURGICAL HISTORY
NIL
FAMILY HISTORY
Her father died due to complication of diabetes mellitus. Her mother still alive and
healthy. All of her siblings are healthy. There is no family history of malignancy.
SOCIAL HISTORY
The patient is a teacher in Ipoh and her husband is a technician. The combined income of
family was RM 3000 which enough to support the family. They lived in single storey house with
adequate water and electric supply. She does not smoke or consume alcohol, however her
husband is a smoker since 5 years ago.
SUMMARY
My patient Puan Farah Salwani 27 years old Malay teacher, primid gravida currently at
34 weeks of gestation who is electively admitted to the hospital due to placenta previa type 4.
She was also diagnosed to have gestational diabetes mellitus which is currently in diet control
and has a strong family history of diabetes. Other than that, she had resolved her asymptomatic
anemia. She had completed IM dexamethasone for fetus lung maturation and currently she was
planning for cesarean section at 38 week of gestation.
PHYSICAL EXAMINATION
GENERAL
This patient was lying comfortably on the bed in supine position. She was alert,
conscious and not tachypnic. There was an iv branula on the left dorsum hand. On examine of
the eye, she was not pale, not jaundice, oral hygiene was good and no central cyanosis. On
examine the hands there was no sign of clubbing, the capillary filling was good and signs of
anemia noted. Her pulse rate was 80 beat per minute, regular rhythm and good volume. On
examining of the leg, there was mild ankle edema. Her weight was 159 cm and her currently
weight was 69 kg.
VITAL SIGN
Pulse rate : 80 beats per min
Blood pressure :115/70 mmHg
Respiratory rate :18 breath per min
Temperature : 37
o
C
NECK
Thyroid was not palpable
BREAST
The breast was symmetrical and no mass was palpable
RESPIRATORY
There was no scar noted on the chest. The chest moved symmetrically with respiration. The
trachea was not deviated. There was no dullness on percussion. Breath sound was vesicular and
normal. Air entry was equal bilaterally.



CARDIOVASCULAR
Jugular venous pressure was not raised. Apex beat palpable at the left 5
th
intercostal
space, lateral to mid clavicular line. On palpation, no thrill and parasternal heave palpable. On
auscultation, both first and second were hears at mitral valve,tricuspid valve,aortic valve and
pulmonary valve. No murmur noted. No 3
rd
heart sound.
NERVOUS SYSTEM
Higher cortical function was intact. He was oriented to time, place and person. His
present and past memory is good. Glasgow Coma Scale was full. Cranial nerves I to XII was
intact. Neurological examination of the upper and lower limbs revealed no abnormality. No
hyperreflexia
ABDOMINAL EXAMINATION
On inspection, the abdomen was distended with gravid uterus by evidence of cutaneous
sign of pregnancy such as linea nigra and striae gravidarum. The umbilicus is centally located
and it was inverted. There was no surgical scar can be noted. Otherwise, abdominal looks
normal.
On light palpation, the abdomen was soft and non-tender, and the uterus was not irritable.
On clinical fundal high revealed it was 34 weeks and the symphysio-fundal height was 34 cm
which correspond to the date. There was a singleton fetus in longitudinal lie and in cephalic
presentation. The fetal back was at right maternal side. The head was 5/5 palpable and not
engaged. The liqua was clinically adequate and estimated fetal weight was 2.4 kg to 2.6 kg.
VAGINAL EXAMINATION
On vaginal examination, no abnormalities detected. Cervix was firm, not effaced with os tip of
finger. The os was not open.



RELEVANT INVESTIGATION AND RESULT
HAEMATOLOGY
To access any feature of anaemic due to haemolysis, sign of infection and sign of pre-eclampsia
such as low platelet.
Full Blood count
White blood cell : 8.68 x 10^3/uL
Red blood cell : 3.95 x 10^6/uL
Haemoglobin : 11.70 g/dl
Packed cell volume (HCT) : 34.70 %
Red cell indicices (MCV) : 87.80 fL
MCH : 27.1 pg
Platelet count : 222.00 x 10^3/uL
Comment: The Hb was in normal range, normal WBC which indicate no sign of infection and
platelet level was normal
COAGULATION PROFILE
To access the coagulation factor
Prothrombin time (PT) : 12.80 sec
Partial Thromboplastin Time (APTT) : 35.50 sec
Comment: Both PT and APTT was normal



BLOOD SUGAR PROFILE.
To access the venous plasma sugar level.
Pre-breakfast Pre-lunch Pre-dinner Before sleep
5.1mmol/l 6.7mmol/l 7.4mmol/l 7.0mmol//

Comment: The level of plasma sugar level at pre-dinner slightly high. Others are within the
normal range.
Urea & Electrolyte With creatinine
In pre-eclampsia, the level of uric acid will be high
Urea : 2.6 mmol/L
Sodium : 135 mmol/L
Potassium : 4.1 mmol/L
Chloride :104 mmol/L
Creatinine :68 umol/L
Uric acid :390 umol/L
Comment: The level of uric acid was normal. Urea and creatinine also was normal

URINALYSIS
Chemical Analysis
Specific gravity : 1.015
pH : 6
Leucocyte : 500 Leu/ul
Nitrite : Negative
Protein : 0.25 g/L
Glucose : Normal
Ketone : Negative
Urobilinogen : Normal
Bilirubin : Negative
Blood : Negative
Comment : protein was negative in urine and leucocyte also normal and to detect whether is
there any sign suggestive of infection
Ultrasound scan
To monitor the AFI as GDM can associate with polyhydroamnions and also to monitor the fetal
development as it can cause macrosomia and also intrauterine death. The ultrasound scan of this
patient shows that the fetal is correspond to the parameter and the liqua is adequate.

Cardiotocograph (CTG)
To monitor the fetal well-being in order to ensure good fetal development. In this patient, CTG
was reactive

Suggestion:
Fundoscopy look for any sign of involvement of the eye such as eye nipping , silver wiring
and other.



PROVISIONAL DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
Placenta Praevia
Placenta praevia exist when the placenta is inserted wholly or in part into the lower segment of
the uterus. Placental migration occurs during the second and third trimesters, owing to the
development of the lower uterine segment. It is hypothesized to be related to
abnormal vascularisation of the endometrium caused by scarring or atrophy from previous
trauma, surgery, or infection. Women with placenta previa often present with painless, bright red
vaginal bleeding. This commonly occurs around 32 weeks of gestation, but can be as early as late
mid-trimester. This bleeding often starts mildly and may increase as the area of placental
separation increases. Praevia should be suspected if there is bleeding after 24 weeks of gestation.
My patient was diagnosed to have placenta praevia at 28 weeks of gestation. Within this period it
is still considered as placenta praevia. Based on the history and clinical examination shown, it is
placenta praevia
DIFFERENTIAL DIAGNOSIS
Placenta Abruptio
Occur when there is separation of a normally situated placenta from uterine wall. It can be either
revealed, concealed or mixed types. Trauma, hypertension, or coagulopathy contributes to the
avulsion of the anchoring placental villi from the expanding lower uterine segment, which in
turn, leads to bleeding into the decidua basalis. This can push the placenta away from the uterus
and cause further bleeding. Bleeding through the vagina, called overt or external bleeding, occurs
80% of the time, though sometimes the blood will pool behind the placenta, known as concealed
or internal placental abruption.
Women may present with vaginal bleeding, abdominal or back pain, abnormal or premature
contractions, fetal distress or death.
Usually the patient will complain of painful vaginal bleeding and the uterus is tense and tender
on palpation. The patient condition also become more severe and distressed compare than
placenta praevias patient.
Vasa praevia
There is rupture of fetal vessels that run in membrane below fetal presenting part which
unsupported by placenta/ umbilical cord. Vasa previa is seen more commonly with velamentous
insertion of the umbilical cord, accessory placental lobes (succenturiate or bilobate placenta),
multiple gestation, IVF pregnancy. In IVF pregnancies incidences as high as one in 300 have
been reported. The reasons for this association are not clear, but disturbed orientation of the
blastocyst at implantation, vanishing embryos and the increased frequency of placental
morphological variations in in vitro fertilisation pregnancies have all been postulated. Fetal
vessels may rupture at spontaneous rupture of membranes (SRM) or be damaged at artificial
rupture of membrane (ARM). Fetal tachycardia may develops followed by deep decelerations.
IDENTIFY PROBLEMS IN TERMS OF PRIORITY
1. Vaginal bleeding
As we know, placenta praevia continues to be an important association with maternal and fetal
morbidity and mortality if there is uncontrolled maternal hemorrhage and fetal hypoxia. In such
cases, we should manage the patient according to the type of placenta praevia either minor or
major. Puan Farah Salwani which is currently at 34 weeks of gestation was diagnosed to have
placenta praevia type 4 which is major. Usually, elective caesarean section should deferred to 38
weeks to minimize neonatal morbidity. Hysterectomy should be mentioned as possibility if
placental percreta happen or overlies a previous scar which can lead to infertility in the future.
However, good news for this patient because she does not has previous scar.
2. High blood glucose level.
She was also diagnosed to has gestational diabetes mellitus. Luckily, this patient has a good
progress for maintaining her blood glucose level. She used to be in diet control. There was no
severe complication to the fetal such as macrosomia or polyhyromnions which may lead to birth
asyphyxia during birth.


IMMEDIATE, SUBSEQUENT MANAGEMENT AND PROGRESSION
The aim of management is to prevent any complication such as fetal distress and maternal
vaginal bleeding Besides that, we want to deliver healthy neonate with minimal maternal
morbidity. Firstly, a complete history taking must be taken and followed by doing physical
examination before admitting the patient into the ward. For this patient, she was admitted to the
ward because she had previous bleeding and the clinician want to manage as inpatient since the
patient current gestation of this patient is at 34 weeks. She was given prophylactic
thromboembolic stocking to decrease the risk of thromboembolism. The doctor also encouraged
her to gentle mobility regularly.
She was also subjected to daily CTG in order to ensure fetus heart rate. On admission,
fetal movement was good, ultrasound shows singleton fetus in longitudinal lie with cephalic
presentation. CTG was also appearing to be normal and it was reactive. 1 large IV line was set
up on her left dorsum hand. Blood was taken to check for full blood count, group screen hold 2
units, blood urea nitrogen. Monitor her vital signs such as blood pressure, pulse rate, and
temperature 4 hourly. Pad chart is used to look for amount if the patient is bleeding again. Other
than that, fetal kick chart is used also to monitor the fetal well-being.
The patient was diagnosed with GDM. Hence, blood sugar profile was done to check her
venous plasma sugar level. BSP was taken at pre-breakfast, pre-lunch, pre-dinner and before
sleep. However the result was not really significant thus, the patient was given an advice to on
diet control. For fetal, ultrasound was done to look for any fetal abnormalities such as big baby,
polyhydroamnions and IUD.
Corticosteroid was given to enhance the lung maturation by stimulate surfactant
production. IM dexamethasone 12mg stat and the second dose were repeated after 12 hours. It is
important to prevent respiratory distress syndrome if the patient is in process of labor which can
lead to preterm labor.
She was planned for elective caesarean section at 38 weeks to minimize neonatal
morbidity. Hysterectomy also was mentioned as possibility to happen during the operation if the
placenta accrete occur.
During pre-operation, again investigation was done; FBC to check for Hemoglobin and
platelet level. BUSE, GSH 2 unit and GXM 4 unit for preparation of blood transfusion if there is
severe bleeding during the operation. The procedure of operation was explained to get consent
from her. The patient was advice to nil by mouth by 12 midnight. Subcutaneous heparin and
cefuroxime were given as a thromboprophylaxis and prophylactic antibiotic. Indwelling bladder
catheter and IV line was set up. The patient was transferred to operation theater in left lateral
position to prevent supine hypotension or fetal distress.
In performing cesarean delivery, low transverse uterine incision is used. Luckily this
patient did not have invasive placentation (accrete, increta, or percreta).
A baby girl was delivered on 2
nd
January 2014 at 8.47 am weighing 2.71 kg via LSCS.
Her apgar score was 9/10. The head circumference was 31 cm and the length of the baby was 50
cm. She was given 1 mg vitamin k and 0.5 ml Hepatitis B injection. Cord blood was collected to
test G6PD and it was negative.At 9 am, the placenta and the membrane were completely
delivered via control cord traction and no retained placenta. The estimated blood loss was 300cc.
The placental weight was 600g.
Postpartum, she was comfortable and not tachypnic with blood pressure 130/75 mmHg and the
pulse was 72bpm. There were no vaginal bleeding and she was not fever. The uterus size was 18
weeks of gestation and well contract. There were no sign of infection. She was prescribing with
Haematinics once daily, subcutaneous heparin 5000U, Synflex tablet and Syrup Lactulose 15mg
were given 3 times daily .






CRITICAL APPRAISAL.
By completing this case write up, which is about placenta praevia, I have learnt a lot
about it started from definition until the management.
Placenta praevia is one of the most common causes of antepartum hemorrhage. Usually,
the patient will presented to you with painless per vaginal bleeding which occur spontaneously.
However, we should elicit any history of trauma, hard exercise and postcoital which can lead to
the vaginal bleeding. It happened when there is tearing of placental attachment and less muscle
to suppress bleeding in lower segment.
There are 4 type of placenta praevia. Type 1 occurred lateral less than 5cm from the os.
Type 2 is marginal which can occur either anterior or posterior part. Type 3 is also known when
placenta partially covering the os. Lastly, type 4 is completely fulling overlying os. Different
type of placenta praevia has its own management. Usually, in minor case such as type 1 and 2,
the patient will recommended to undergo spontaneous vaginal delivery (SVD). While on the
other types which is considered a major case, elective caesarean section is usually done to them.
For this case, this patient started to has placenta praevia at 28 weeks of gestation without
significant per vaginal bleeding. So, we can say that this patient has antepartum haemorrhage
since from definition APH occur after 24 weeks of gestation. Apart from that, the patient also
was diagnosed to has GDM with onset or first recognition during pregnancy. Increased estrogen
and progesterone, degradation of insulin by placenta and increase cortisol and hPL can lead to
hyperglycemia in maternal body ultimately it will promote carbohydrate intolerance in
pregnancy.
So, it is important to monitor the patient condition, sign and symptoms and complication
of placenta praevia and GDM.
The safest, simplest, and most precise method of placental localization is by using
transabdominal sonography or transvaginal sonography. All patients with minor placenta praevia
can be manage conservatively and treat as outpatient. In patient with major placenta praevia, if
no previous bleeding, careful counselling should be made before contempting outpatient care. If
patient had previous bleeding, they should be admitted and managed as inpatients form 34 weeks
of gestation. However, prolong inpatient care can be associated with thromboembolism. Thus,
gently mobility should be encouraged together with the use of prophylactic thromboembolic
stockings. Prophylactic anticoagulation should be reserved for those at high risk of
thromboembolism. We also can educate the patients to not having abdomen massage, no coital
and immediate admit if there is contraction feel.
Monitor the patient blood pressure, pulse rate and pad chart. Correct the anaemia until the
haemoglobin level reach at least 11g/dL. We should also monitor the fetal well-being by using
fetal-kick chart, CTG, and serial scan for growth because there is high chance for the baby to has
hypoxia and IUGR. Other than that, we can give 2 dose IM dexamethasone 12mg stat 12 hours
apart for fetal lung maturation. Immediate caesarean section is indicated if gestational age is
more than 36 weeks of gestation, profuse bleeding and fetal distress. All minor case can proceed
with spontaneous vaginal delivery while all major case elective caesarean section should be
considered at 38 weeks of gestation.
There are several complications of GDM that can happen to the fetal and maternal. During 1
st

trimester, there will be congenital abnormalities occur to the fetal such as VSD, ASD, neural
tube defect and sacral agenesis. While during 2
nd
trimester macrosomia and polyhydoamnions
much more indicated which may lead to birth asphyxia and shoulder dystocia. After the delivery,
baby may suffer respiratory distress syndrome, hypoglycemia and hypomagnesaemia. Maternal
may suffered microangiopathy, ketoacidosis, hyperglycaemia and prone to have infection.
For reason my patient has a strong family history with diabetes mellitus. Her father was dead
due to complication of DM. Hence, a 2 hour 75g glucose 250ml, oral glucose tolerance test
(OGTT) at 16-18 weeks to test for gestational diabetes was indicated for this woman. Normally
at 0-hour plasma glucose value should be less than 5.6 mmol/L. At 2-hour plasma glucose value
should be less than 7.8mmol/L. If the level of plasma glucose value high than these it is
considered as GDM.
After diagnosed, consult them lifestyle and diet changes. Blood sugar profile is done after 1-2
weeks. Venous plasma sugar level was taken at pre-breakfast, pre-lunch, pre-dinner, and before
sleep. If range between 4-7 mmol/l, consider diet therapy. If more than 7mmol/l or types 1
diabetes or ultrasound show fetal macrosomia, start insulin (actrapid 4-6 unit tds) admit patient
for education of therapy. HbA1c should be check for every trimester (especially 1
st
trimester)
and maintain between 4-7% to check risk of fetal malformation.
Full term SVD delivery may be the choices of delivery if no other obstetrics complications. If
the patient on insulin we can deliver at 38-40 weeks. But, if DM uncontrolled with fetal
compromised should electively deliver the baby as soon as possible. Elective c-sec is indicated if
the patiet has big baby, poor DM control, vascular complication, history of subfertility, and bad
obstetric history.
For my patient, she does not have any complication of GDM because she has a good and well
controlled performance for her blood glucose profile. However, since she had a placenta praevia
major, she underwent LSCS.













DISCHARGE SUMMARY
Puan Farah Salwani is a 27 years old Malay Primid gravida with 4 day post LSCS delivery at 38
weeks period of gestation.
VITAL SIGN
Pulse rate : 80 beats per min
Blood pressure :118/75 mmHg
Respiratory rate :18 breath per min
Temperature : 37
o
C

Problems:
1. Placenta Praevia type 4
She underwent LSCS on 38 weeks period of gestation with no severe complications.
Given birth to baby girl:
Birth weight 2.71 kg
Apgar score is 9
G6PD: negative
Active, pink,
Currently, patient is:
Comfortable, afebrile
The blood pressure is in normal range
Tolerating orally
On examination,
Alert, comfortable
Pink
Vital sign stable, afebrile
The abdomen is soft and non-tender
Uterus well contracted at 18 weeks size
Plan:
1. Allow discharge today
2. TCA 2 weeks later for blood pressure monitoring
3. Discharged medication:
T.Ponstant and T.Gelusil 11/11 tds
T.Haematinics 1/1 od
Syrup lactulose 15ml tds


( DR MUHAMMAD
KHAIRI AMMAR )
Medical officer
O&G Department
Hospital Kulim










REFERRAL LATER

HOSPITAL KULIM
Jalan Mahang, 09000 Kulim.Kedah.
Tel: 04 4903333. Fax: 04 4900760.
URL: http://hkulim.moh.gov.my

To : House Officer/ Medical Officer/ Specialist
Patient Name: FARAH SALWANI
Dear doctor,
Thank you for seeing this patient and for your concern. We would like you to facilitate this
patient follow up visits in your health clinic.
This is Puan Farah Salwani is a 27 years old Primid gravida, currently 4 day post vaginal
delivery after underwent LSCS
Problems:
1. She was diagnosed to have placenta praevia type 4.
She has undergone for LSCS was done. The labour was progress well with no other
complication.
Upon discharged, both mother and baby was healthy. Maternal blood pressure was 118/75 and
other vital sign was normal. She was afebrile and can tolerate orally.
Patient was prescribed with:
T.Ponstant and T.Gelusil 11/11 tds
T.Haematinics 1/1 od
Syrup lactulose 15ml tds
Kindly please see this patient for:
1. Family planning consultation
2. Explain the complications for next pregnancy




( DR MUHAMMAD
KHAIRI AMMAR )
Medical officer
O&G Department
Hospital Kulim



















PRESCRIPTION

HOSPITAL KULIM
Jalan Mahang, 09000 Kulim.Kedah.
Tel: 04 4903333. Fax: 04 4900760.


PATIENT NAME : FARAH SALWANI
Patient is prescribed with,
1. T.Ponstant 11/11 tds
2. T.Gelusil 11/11 tds
3. T.Haematinics 1/1 od
4. Syrup lactulose 15ml tds




( DR MUHAMMAD
KHAIRI AMMAR )
Medical officer
O&G Department
Hospital Kulim







PROFESSIONAL COMPONENT
PART I: ISSUE ON PROFESSIONALISM
Professional etiquette is one of the most important factors contributing to a successful
healthcare career. Healthcare involves many personal interactions with a variety of people.
Etiquette in healthcare is more than just good manners; it is about establishing respectable
relationships with patients, colleagues, and supervisors.
I learnt that I need to be brave and confident when communicating with the patients. I
tried my best to use simple questions so that my patients would understand my questions easily
and would not feel burden to answer them. I felt comfortable to talk with her as she was always
smiling and cooperative with me. She gave me permission to do physical examination on her and
she even asked me about the Leopard Maneuvar as she found that it is very interesting. I palpated
her abdomen as gentle as possible while explaining to her and she was very amazed. I was very
happy that I can palpate the fetal parts and at the same time share my experiences with the
patient. This is a very precious experience as I cannot easily get the opportunity to approach
someone who I did not know about her whereabouts before, and try to convince her to believe in
me.
At the beginning, of and throughout the patient and doctor relationship, the physician
must work toward an understanding of patients health problem. After the patient agree on the
problem and the goals of therapy, the physician must be professionally competent, act
responsibly and treat the patient with compassion and respect. In the care, including giving
informed consent or refusal to care as the case might be.
The physicians primary commitment must always to the patients welfare and best
interests, whether in preventing or treating illness or helping patient to cope with illness
disability and death. The physician must respect the dignity of all persons and respect their
uniqueness. The interest of patient should always be promoted regardless of financial
arrangements, decision making capacity, behavior and social status.


PART II: REFLECTION & LIFE LONG LEARNING:

The patient has the right to expect good quality in healthcare. Patient must be treated in
such way that their beliefs and privacy are respected and their dignity remains unoffended. In my
case, my patient was diagnosed to have placenta praevia type 4 which is major.
As we all known that placenta previa can create a lot of complications especially to the
mother. In severe case, we should not forget to mention hysterectomy to the patient. Since this is
the 1
st
pregnancy of my patient, we should also taking care of her emotions as there is chance for
to not get pregnant anymore. Luckily, this patient did not have any severe complication during
the operation and her uterus is still intact. Unfortunately, she might has problem which can affect
for the next pregnancy as she had a scar. So, I learned that we should always explain and educate
the patient regarding her condition so that she will be more caution in the future.
As a medical student, I need to practice more on communication skill. I learnt how to
become more alert and sensitive towards patients and be more considerate in getting information.
From the practice, I got a lot of advantages that can help me to improve my skills to understand
the patients conditions and needs.

The patient-physician relationship entails special obligations for the physician to serve
the patients interest because of the specialized knowledge that physician possess. Effective
communication is critical to a strong patient- physician relationship. At that time, I learned that it
is important to gain trust and having a good communication between a doctor and the patient.
The efforts and commitments from the doctor also give me inspiration to do my very best in
treating my patient. I believe that I should take an initiative to not only treating my patient, I also
need to respect and take care of them earnestly.



REFERENCES.

Redman C W G 1989. Hypertension in pregnancy. Medical disorder in obstetric practise.
Blackwell scientific oxford
Fenakel et al : nifedipine versus hydralazine in the management of preeclampsia ,
obstetric and gynaecology 77 : 731 1991
Repke JT, Villar J : Pregnancy induced hypertension and low birth weight : the role of
calcium 1991
Labib M. Ghulmiyyah and Baha m. Sibai, gestational hypertension-preeclampsia and
eclampsia ,management of high risk pregnancy : an evidence based approached
Pipkin FB,Risk factor for pre-eclampsia,2001
Berkowitz KM,Insulin resitance and preelampsia,1998
Ten Teachers. 2011. Obstetrics 19
th
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