Ob Case Write Up

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Identifying Data
JJ is a 38-year old female, Chinese, Roman Catholic, married, residing in Pasig City.

Chief Complaint: vaginal bleeding, 1 day

History of Present Illness
LMP = April 21, 2010PMP = March 2010AOG = 27 6/7 weeksEDD = Jan. 26, 2011

The present condition started about an hour prior to consult. The patient while walking around the mall experienced sudden onset of passage of bloody vaginal discharge of unknown quantity. There was no associated hypogastric pain, uterine contraction, or watery vaginal discharge. Patient at the time also noted good fetal tone. The bleeding persisted hence the consult.

Trimester History
During the first trimester patient only took multivitamins and folic acid and no other medications. She completed her monthly check-ups with her attending physician. Patient had no exposure to any illness, radiation, or teratogens. In the second trimester, at the 23rd week of pregnancy, patient noted watery discharge, fluid in consistency amounting to 1 teaspoon staining her underwear. There was no blood or mucoid noted at the time and patient did not experience any uterine contraction. There was good fetal tone. Patient then sought consult and was worked up. It was found out that patient had premature preterm rupture of membrane. No medications were given. Instead patient was advised to come back on her 28th week of pregnancy for follow up. Prior to the present complaint, pregnancy history was unremarkable.

Past Medical History
The patient was diagnosed to have diabetes mellitus type II last 2006 and is currently taking metformin for maintenance. She was also diagnosed to be hypertensive last 2007. Other than the mentioned illnesses, patient does not have any history of thyroid disease, cardiac disease, nor cancer. Patient also does not have any allergies to food or medications.

Ob/Gyn History
The patient is a multigravid with no past obstetrical complaints, hospitalizations, or surgeries. Patient had her menarche was at the age of 12. Menstruation is usually every 28-30 days, lasting for 3-5 days, consuming 3-4 pads per day. Patient mentions experiencing dysmenorrhea during her monthly periods. Patient was 28 years old during her first pregnancy and had two partners including her current husband. The couple admitted to occasional use of condoms. Patient denies having any history of pelvic infection or sexually transmitted infections.

Gravida| Outcome| Date| AOG| Sex | Birth Wt.| Status| 1| CS due to oligohydramnios| 2002| Full term| Male| 7 lbs.| living| 2| Current pregnancy| | | | | |

Family History
At time of the interview, the patient is living with her husband their first born. The patient’s mother is a hypertensive and diabetic. No other pertinent disease exists in the family.

Personal and Social History
The patient is a non-smoker and not an alcoholic beverage drinker. The patient has no history of substance abuse. The patient is married and is a college graduate and currently employed at the Philippine Gaming Commission.

* no nausea, no vomiting, no dysphagia
* no changes in bowel movement
* no changes in urination, dyuria
* no blurring of vision
* no easy bruisability, no past transfusions
* no change in disposition
* no headache, no dizziness

Physical Examination

RT is a 36-year old woman who is alert, coherent, and not in cardio-respiratory distress.

Vitals. HR 86/min; RR 20/min; BP 132/73 right arm, supine; T 37.7°C HEENT. The patient has anicteric sclerae, pink conjunctivae, no tonsillopharyngeal congestion, no cervical lymphadenopathies, and flat neck veins. Thorax and lungs. Thorax symmetric with equal chest expansion. Clear breath sounds. No wheezes, rhonchi, or...
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