Ob Case Study

Only available on StudyMode
  • Download(s): 72
  • Published: May 14, 2013
Open Document
Text Preview
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 OB score is G4P2(2012)

# of Preg| Date| AOG| Manner| Place| Sex| BW| Present Status| Complications| G1| 2005| 3 mos| -| Home| -| -| -| Spontaneous Abortion| G2| 2006| FT| VSD| UMC| M| 2.9kg| Live| None|

G3| 2010| FT| VSD| UMC| F| 2.9kg| Live| None|
G4| PP| | | | | | | |

IX. Gynecologic History
The patient has no history of breast diseases. The patient did not have any gynecologic surgeries or procedures done. She did not have an HPV vaccine. The patient did not have any history of infertility. The patient had her pap smear last 2009 which revealed normal results and no abnormalities. There was no history of foul smelling vaginal discharge or pruritus.

X. Contraceptive History
The patient has no history of use of contraceptive pills or other contraceptive methods.

XI. History of Present Pregnancy
LNMP: July 23, 2012
PMP: Third week of June 2012
EDC: April 30, 2013
AOG by LNMP: 38 1/7
AOG by UTZ: 38 2/7
Quickening: 16 wks AOG

Seven months prior to admission, around 7 weeks AOG, patient noticed that she was amenorrheic. She took a pregnancy test which turned out to be positive. Patient did not experience morning sickness, nausea or vomiting. No consult was done.

Five months prior to admission, around 16 weeks AOG, patient first felt her baby move. Patient claimed that her blood pressure was 130/80. Patient did not experience morning sickness, nausea or vomiting. No consult was done.

Four months prior to admission, around 20 weeks AOG, patient consulted at DLSUMC OPD for her prenatal checkup. Lab tests done were CBC, blood typing, routine urinalysis, HbsAg, ultrasound and VDRL/RPR. Patient did not experience morning sickness, nausea or vomiting. Patient’s blood pressure was noted to be 110/60. The fundic height at this time was 18cms.

Three months prior to admission, around 24 weeks AOG, patient was requested to have 50g OGCT which gave a result of 109.18. Patient also noticed...
tracking img