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Tamo, Bb Boy

Maternal History
PNCU OSMAK 10/02/15
21
G2P1 (1001)
LMP: Feb 20, 2015 (sure)
AOG:
32 weeks by LMP
32 3/7 weeks by EUTZ
CC: PNCU x 1
FIRST TRIMESTER
PT positive last May 2015. 1st PNCU at 3 months AOG (May 28) c/o Healthway Market! Market! with
regular visits (x2 visits). Patient denies exposure to radiation nor viral exanthems. No UTI and BP
elevation. Regular intake of Folic Acid.
SECOND TRIMESTER
Quickening at 6 mos AOG. No PNCU done. No UTI and BP elevation. Regular intake of Folic acid OD.
THIRD TRIMESTER
No PNCU done. No UTI and BP elevation. Regular intake of folic acid OD. This is the 1st PNCU of the
patient at our institution.
Good fetal movement
No watery/bloody discharge
No regular contractions
Past Medical History:
(-) DM
(-) HPN
(-) Asthma
No previous operation
No allergy to food and drugs
Family History:
(-) DM
(-) HPN
(-) Asthma
(-) Thyroid disease
Personal/ Social History:
Non-smoker
Occasional alcoholic beverage drinker (stopped during pregnancy)
College undergraduate (2nd year college)
Call center agent
Lives with partner
Menstrual History:
M 15 y/o
I irregular, every 28-30 days, became irregular when the patient started to use injectable
contraceptives (2013)
D 5-7 days
A 2-3 ppd, moderately soaked
S (-) dysmenorrhea

Contraceptive Hx:
(-) IUD
(-) OCP
(+) Injectables (2013)
Sexual History:
1st coitus: 18 y/o
Sexual partner/s: 2
1) student
2) front desk officer, currently monogamous
(-) Pap smear
OB History:
G1 2013, NSD, live term baby boy, OsMak, EFW 7 lbs, no complications
G2 Current pregnancy

EUTZ (May 30, 2015)


SLIUP
cephalic
14 4/7 weeks AOG
140 bpm
AFI: 3.4 (SVP), normohydramnios
EFW: 96g
Placenta posterior grade 0 high lying
Assessment: G2P1(1001) 32 weeks cephalic not in labor
Plan:
For CBC with PC, HbsAg, RPR, ABO, 75 g OGTT
For PAP smear
For pelvic ultrasound
Start multivitamins, 1 tab OD
Start FeSO4, 1 tab OD
Drink 1 glass of milk BID
To OB ER anytime if with regular uterine contractions, decreased fetal movements, watery/bloody
vaginal discharge
For OB OPD follow-up on October 30 2015 9am at OB OPD
Advised family planning
Daily perineal hygiene
Well advised
FOR REFERRAL TO HC once with NORMAL LABS
LABS (Oct 28):
RPR: nonreactive
UA
UTZ
Oct 30
21
G2P1 (1001)
LMP: Feb 20, 2015 (sure)

AOG:
36 weeks by LMP
36 weeks by EUTZ ( May 30 2015 14 1/7)
Good fetal movement
No watery/bloody discharge
No regular contractions
Conscious, coherent
Vitals BP 100/70
Wt. 73.9 kg
Anicteric sclerae, pink palpebral conjunctivae
Symmetric chest expansion, clear breath sounds
Adynamic precordium, normal rate, regular rhythm, no murmurs
Globular abdomen
FH: 30 cm FHT: 140 bpm
Full and equal pulses
G2P1(1001) 36 weeks cephalic not in labor
noted Hfb of 8.3
Hct of .31
referred case to dr canaveral for iron sucrose 2 ampules tiv now then 2 ampules after 3 days for 3
doses then repeat cbc after 1 week of the last dose
cont multivitamins, 1 tab OD
cont FeSO4, 1 tab OD
Drink 1 glass of milk BID
To OB ER anytime if with regular uterine contractions, decreased fetal movements, watery/bloody
vaginal discharge
For OB OPD follow-up on nov 2 2015 9am at OB OPD
Advised family planning
Daily perineal hygiene
Well advised
Nov 2
21
G2P1 (1001)
LMP: Feb 20, 2015 (sure)
AOG:
36 3/7 weeks by LMP
36 3/7 weeks by EUTZ (May 30 2015 14 1/7)
CC: PNCU x 3
Good fetal movement
No watery/bloody discharge
No regular contractions
ROS:
no subjective complaints
no dysuria
no dizziness
Noted Hgb of 8.3 and Hct of .31 last Oct 30, 2015

1st dose of iron sucrose 2 ampules TIV administered last Oct. 30, 2015
Conscious, coherent
BP 110/80 Wt. 75.8 kg
Anicteric sclerae, Pink palpebral conjunctivae
Symmetric chest expansion, clear breath sounds
Adynamic precordium, normal rate, regular rhythm, no murmurs
Globular abdomen
FH: 33 cm FHT: 140 bpm, RLQ
SE/IE: not done
Full and equal pulses
No pallor
G2P1 (1001) 36 weeks, cephalic, not in labor
For 2nd dose of iron sucrose, 2 ampules TIV now
For 3rd dose of iron sucrose, 2 ampules TIV on Nov. 5, 2015 (2 doses completed)
For repeat CBC after 1 week of 3rd dose
Continue multivitamins, 1 tab OD
Continue FeSO4, 1 tab BID
Drink 1 glass of milk BID
To OB ER anytime if with regular uterine contractions, decreased fetal movements, watery/bloody
vaginal discharge
For OB OPD follow-up on Nov. 5, 2015, 9am
Advised family planning
Daily perineal hygiene
Well advised
Nov 5
21
G2P1 (1001)
LMP: Feb 20, 2015 (sure)
AOG:
36 4/7 weeks by LMP
36 4/7 weeks by EUTZ (May 30 2015 14 1/7)
CC: PNCU x 3
Good fetal movement
No watery/bloody discharge
No regular contractions
ROS:
no subjective complaints
no dysuria
no dizziness
Noted Hgb of 8.3 and Hct of .31 last Oct 30, 2015
2nd dose of iron sucrose 2 ampules TIV administered last Nov 2, 2015

Conscious, coherent
BP 110/80 Wt. 75.8 kg
Anicteric sclerae, Pink palpebral conjunctivae
Symmetric chest expansion, clear breath sounds
Adynamic precordium, normal rate, regular rhythm, no murmurs
Globular abdomen
FH: 33 cm FHT: 140 bpm, RLQ
SE/IE: not done
Full and equal pulses
No pallor
G2P1 (1001) 36 4/7 weeks, cephalic, not in labor
Anemia probably nutritional
referred case to dr canaveral for iron sucrose 2 ampules tiv now then 2 ampules after 3 days for 3
doses (3rd dose given)then repeat cbc after 1 week of the last dose
cont multivitamins, 1 tab OD
cont FeSO4, 1 tab OD
Drink 1 glass of milk BID
To OB ER anytime if with regular uterine contractions, decreased fetal movements, watery/bloody
vaginal discharge
For OB OPD follow-up on nov 24 2015 9am at OB OPD
Advised family planning
Daily perineal hygiene
Well advised
Nov 24
21
G2P1 (1001)
LMP: Feb 20, 2015 (sure)
AOG: 39 weeks 4 days
GOOD FETAL MOVEMENTS
NO WATERY OR BLOODY VAGINAL DISCHARGE
NO CONTRACTIONS
conscious, coherent ambulatory not in distress
anicteric sclerae, pink palpebral conjuctivae
symmetric chest expansion, clear breath sounds
adynamic precordium, normal rate, regular rhythm, no murmurs
globular FH: 31 cm FHT: 150 bpm
SE:cervix violaceous, no mass, no erosions, no bleeding per os
IE: normal looking external genitalia, parous introitus, vagina admits 2 fingers with ease, cervix 1 cm
dilated, beginning effacement, (+) BOW, cephalic, floating
full and equal pulses, (-) cyanosis, (-) edema
G1PO PU 39 weeks
cephalic in beginning labor
for NST
refer
MAY GO HOME
continue multivitamins tab 1 tab once daily
continue ferrous sulfate tab 1 tab once daily
START EVENING PRIMROSE OILCAP 1 CAP EVERY 8 HOURS

1 glass of milk daily


OB OPD on 11/28 8AM WITH BPS
OB ER if with bloody or watery vaginal discharge, decrease fetal movements, uterine contractions
fetal kick monitoring
well advised
Nov 28
21
G2P1 (1001)
LMP: Feb 20, 2015 (sure)
AOG: 40 weeks 1 day
PNCU
Good fetal movement
No watery of bloody vaginal discharge
with regular uterine contractions
BPS 11/24
Single live intrauterine pregnancy, cephalic in presentation compatible with 39 weeks and 4 days
gestational age.
Good Biophysical Score 8/8
Grade II right lateral placenta
EFW: 3909 grams
EDD: November 27, 2015
BPS UTZ:
Single live intrauterine pregnancy, cephalic in presentation compatible with 39 weeks and 6 days
gestational age.
FHT: 133 bpm
AFI: 15.8cm
Good Biophysical Score 8/8
Grade II right lateral placenta
EFW: 4033 grams
conscious, coherent ambulatory not in distress
anicteric sclerae, pink palpebral conjuctivae
symmetric chest expansion, clear breath sounds
adynamic precordium, normal rate, regular rhythm, no murmurs
globular FH: 32 cm FHT: 150 bpm
SE:cervix violaceous, no mass, no erosions, no bleeding per os
IE: normal looking external genitalia, parous introitus, vagina admits 2 fingers with ease, cervix 3cm
dilated, in beginning effacement, (+) BOW, cephalic, St -3
full and equal pulses, (-) cyanosis, (-) edema
G2P1 (1001) 40 weeks AOG cephalic in beginning labor
For BPS UTZ
seen by intern Sandoval
Referred to dr de guzman/bunda
May go home
For iron sucrose 2 ampules TIV
Take home medications:
1. Multivitamins 1tablet once a day

2. ferrous sulfate 325mg/tab 1tablet 2 x a day


3. Evening primrose 1000mg/capsule 1capsule every 8 hours
4. Hyoscine N Butyl Bromide 10mg/tab 1tablet every 8 hours
OB OPD on 12/1/15 8AM WITH BPS UTZ
OB ER if with bloody or watery vaginal discharge, decrease fetal movements, uterine contractions
fetal kick monitoring
well advised
OB IN PATIENT
21
G2P1 (1001)
LMP: Feb 20, 2015 (sure)
AOG: 39 weeks 4 days
cc: Labor pains
Few hours PTC
GOOD FETAL MOVEMENTS
NO WATERY OR BLOODY VAGINAL DISCHARGE
NO CONTRACTIONS
Prompted consult
conscious, coherent ambulatory not in distress
anicteric sclerae, pink palpebral conjuctivae
symmetric chest expansion, clear breath sounds
adynamic precordium, normal rate, regular rhythm, no murmurs
globular FH: 31 cm FHT: 150 bpm
SE:cervix violaceous, no mass, no erosions, no bleeding per os
IE: normal looking external genitalia, parous introitus, vagina admits 2 fingers with ease, cervix 6 cm
dilated, 60% effacement, (+) BOW, cephalic, St -3
full and equal pulses, (-) cyanosis, (-) edema
G2P1 (1001) PU 39 weeks cephalic in labor