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Ob Case Study

By | May 2013
Page 1 of 10
CLINICAL HISTORY

I. General Data
F.B., 30 years old, G4P2(2012), married, Filipino, Roman Catholic, housewife, born in Don Carlos, Metro Manila, and currently residing in Zone III, Sampaloc, Dasmarinas, Cavite, was admitted for the third time at DLSUMC on April 16, 2013 at around 9:30am.

II. Chief Complaints
Labor pains and passage of watery vaginal discharge

III. Past Medical History
The patient has a history of hypertension since 2006. It was diagnosed since her second pregnancy. Her BP would range from 130/90 to 160/100. Patient took Amlodipine, 5mg, for her hypertension, even when she was not pregnant. Aside from hypertension, the patient has no history of asthma, diabetes, cardiac disease, thyroid disease, epilepsy, hepatitis and allergies.

IV. Family History
The patient has a family history of hypertension and asthma on her paternal side. No other family history of diabetes, cardiac disease, thyroid disease, epilepsy, hepatitis and allergies were noted.

V. Personal and Social History
The patient is a highschool graduate who is a housewife. She is a non-smoker and non-alcoholic beverage drinker. She denies ever using any illegal drugs. She is married to B.B. for 8 years, a highschool graduate who works as a cement mixer. He is a smoker and alcoholic beverage drinker.

VI. Menstrual History
The patient had her menarche at the age of 12 years old with regular monthly cycle lasting for 4 days. She uses 3 moderately soaked overnight sanitary napkins per day. She sometimes experiences dysmenorrhea during her period. She does not take any medications for her dysmenorrhea.

VII. Sexual History
The patient had her first sexual intercourse at the age of 22 years old. She and her husband are both monogamous. Her last sexual intercourse was on March 2013. She has sexual intercourse with her husband 1-3 times a month. She does not experience dyspareunia or postcoital bleeding.

VIII. Obstetric History
The patient’s...
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