Identify the History of present illness and Past healthHistory
Patient Identification: SB, 20 y/o, Gravida 1 Para 0, Single,Filipino, Catholic, High School graduate, Pasig City
Chief Complaint: Labor pains
History of present condition
3 hours prior to admission patient complained of contractions,irregular, occurring every hour with associated hypogastric pain.There was no watery vaginal discharge noted. She also claims ofgood fetal movement. 2 hours prior to admission there was vaginalspotting noted with no associated mucoid discharge. There was nofever nor cough and colds noted.
Few minutes prior to admission, she complained of uterinecontractions occurring every
every 5 minutes with increasing frequency, lasting for 20-30seconds with associated hypogastric pain and vaginal spotting.Persistence of condition prompted consult, hence admission.
HISTORY OF PRESENT PREGNANCY:
FIRST TRIMESTER
(+) cessation of menses
Pregnancy home kit test: positive
(+) prenatal check-up at Barangay Health Center
(-) laboratory work-up
(-) Transvaginal ultrasound
(+) intake of Folic Acid 1 tab once a day
(-) vaginal bleeding
(-) hypogastric pain
(-) maternal illness
(-) exposure to radiation and teratogens
SECOND TRIMESTER
(+) prenatal check-up at Rizal Medical Center
(+) intake of multivitamins & ferrous sulfate
(+) laboratory work-up
(-) no ultrasound
(+) quickening at 5 months
(-) vaginal bleeding
(-) vaginal discharge
(-) hypogastric pain
(-) maternal illness
(-) exposure to radiation and teratogens
THIRD TRIMESTER
(+) prenatal check-up Makabali Medical Center
(+) intake of multivitamins & ferrous sulfate
(+) Ultrasound was done
(-) vaginal bleeding
(-) vaginal discharge
(-) hypogastric pain
(-) maternal illness
Past Medical History
(-) Diabetes Mellitus
(-) Hypertension
(-) Goiter
(-) Asthma
(-) Allergy
(-) Surgery
Family History
(-) Diabetes Mellitus
(-) Hypertension
(-) Heart disease
(-) Kidney disease
(-) Cancer
Personal & Social History
(-) smoker
(-) Alcoholic drinker
(-) social prohibited drugs
Menstrual History
Menarche: 12 y/o
Interval: every 28-32 days
Duration: 4-5 days
Amount: 3 pads per day, fully soaked
Symptoms: (-) dysmenorrhea
Obstetrical History
Gravida 1 Para 0
LMP: May 17-21, 2018 (sure)
AOG: 38 4/7 weeks by LMP
Gynecologic & Sexual History
Coitarche: 17
Sexual Partners: 2
(-) OCP use
(-) STI
Review of Systems
General: (-) fever, malaise, fatigue and sweating
Skin: (-) hyperpigmentation, pruritus, rash
Eyes/Ears: (-) blurring of vision, redness, pain, (-) hearingloss, otalgia, discharge
Nose/Throat/Mouth: (-) nasal obstruction, (-) frequent cough& colds, neck mass
Respiratory: (-) sputum, (-) DOB, (-) hemoptysis
Cardiovascular: (-) palpitations, (-) syncope, (-) chestpain
Gastrointestinal: (-) dysphagia, melena, heartburn,hematemesis
Urinary: (-) dysuria, (-) urgency, (-) frequency, (-)nocturia
Genitoreproductive: (-) abdominal vaginal bleeding
Extremities: (-) cyanosis, clubbing, edema, ulcers
Nervous system: (-) headache, (-) fainting spells, (-)dizziness
Muskuloskeletal: (-) joint stiffness, (-) pain
Physical Examination
BP: 110/70 mmHg CR: 81bpm RR: 18cpm Temp: 36.7 C
Wt: 61kg Ht: 1.58m BMI: 20.58
Conscious, coherent, not in cardiopulmonary distress
Pink palpebral conjunctivae, anicteric sclerae
Symmetrical chest expansion, clear breath sounds, no crackles,no wheezes
Adynamic precordium, normal rate, regular rhythm, no murmur
Abdomen: globular, nontender
Fundic height: 30 cm
Fetal Heart Tones: 142bpm
Internal Examination: 4cm, 30% effaced, leaking bag of waters(clear), cephalic, station -2
Full and equal pulses
FH: 30cm (EFW: 3,100 grams)
FHT: 142 bpm
IE: 4 cm dilated, 30% effaced, (+) bag of water, cephalic,station -2
Bishop’s Score: 4
CLINICAL PELVIMETRY:
Sacral promontory not easily reached at 11 cm
Sacrum deep & well curved
Sacrosciatic notch wide
Ischial spines not prominent
Side walls Divergent
Pubic arch wide
Admitting Diagnosis: Gravida 1 Para 0 Pregnancy Uterine 38 4/7weeks Age of Gestation, Cephalic in labor
Plan: For Normal Spontaneous delivery followed by PostpartumImplanon Insertion
Course at the labor room
Upon admission: patient was placed on Low residue diet.Intrapartal assessment was done which showed category I tracing andwas placed under labor watch. Contractions were moderate, lastingfor 20-30 seconds at 3-5 minutes interval
IE: 4cm, 30% effaced, (+) BOW, cephalic, st -2
2nd hour: Contractions were still moderate, lasting for 30-40seconds occurring every 2-3 minutes interval
IE: 5cm, 50% effaced, (-) BOW, cephalic, st -2
4th hour: contractions were strong, lasting for 40-50 secondsoccurring every 2-3 minutes interval, Intravenous oxytocin wasstarted
IE: 5cm, 50% effaced, (-) BOW, cephalic, st -2
6th hour: contractions were strong, lasting for 50-60 secondsoccurring every 2-3 minutes interval
IE: 7 cm, 70% effaced, (-) BOW, cephalic, st -1
8th hour: contractions were strong, lasting for 50-60 seconds at2-3 minutes interval.
IE: 9 cm, 80% effaced, (-) BOW cephalic, st -1
10th hour: contractions were strong, lasting for 50-60 secondsat 2-3 minutes interval.
IE: fully dilated fully effaced, (-) BOW, cephalic, st 0
