De Oca, Maria Goldie June

• 41/M
• G3P2(2002)
• CC: labor pains
• 1 day prior to admission, patient had onset of irregular uterine contractions
occurring 1-2 episodes in an hour, lasting ~30 seconds, mild in intensity.
Patient had her Scheduled PNCU and IE was done revealing closed cervix.
Patient was advised admission for induction of labor.
• (+) active fetal movements
• (-) watery vaginal discharge
• (-) vaginal bleeding
 PAST MEDICAL HISTORY
 (-) Hypertension
 (-) Diabetes Mellitus
 (-) Bronchial Asthma
 (-) Thyroid/ Cardiac disorder
 (-) Previous surgery
 (-) FDA

 FAMILY HISTORY
 (+) Hypertension- paternal side
 (+) Diabetes Mellitus- paternal side
 (+) Congestive Heart Failure- Father
 (-) Bronchial Asthma
 (-) PTB
 (-) Cancer

 PERSONAL & SOCIAL HISTORY

 Non-smoker
 Non-alcoholic beverage drinker
 Sales representative
 OB/GYNE HISTORY
 G3P2(2002)

MENSTRUAL HISTORY
Menarche: 12 years old G1-2007-F-FT- NSVD-6lbs 3 oz-RMC
Interval: regular G2-2008-F-FT- NSVD-5lbs 13 oz-RMC
Duration: 7 days G3-present pregnancy
Amount: 3-4 pads/day, moderately soaked
Symptoms: (-) dysmenorrhea LMP: Sept 10, 2017
AOG: 41 1/7 weeks by LMP
 Coitarche: 28
EDC: June 17, 2018 by LMP
 # SP: 1
 Family planning: Calendar method
 (+) OCP use- 2010- Ethinyl estradiol +
Levonorgestrol (Trust pills) x 3 months
 Papsmear- 2017- unremarkable
OB Course:
1st PNCU: 1 month AOG w/ AP, total of >10 visits
4 weeks AOG- threatened abortion- Isoxuprine (Isoxilan) 10mg/tab, 1 tab TID x
2 weeks
8 weeks AOG- URTI- Nasathera BID x 5 days
12 weeks AOG- threatened abortion- Isoxuprine (Isoxilan) 10mg/tab, 1 tab TID x
2 weeks

2nd and 3rd trimester- unremarkable

Supplements: MTV + Fe 1 cap OD; Calcium 1 cap BID

 PHYSICAL EXAMINATION
 BP 110/80 mmHg | HR 90 | RR 20 | T 36
 Ht 5’3” Wt 62 kg BMI 24.21
 Awake, ambulatory, not in cardiopulmonary distress
 Anicteric sclerae, pinkish palpebral conjunctivae
 Symmetrical chest expansion with clear breath
sounds
 Adynamic precordium with regular rate and rhythm
 Breasts symmetrical without lesions nor masses
 Gravid abdomen
 FH: 32 cm
 FHB: 138 bpm
 EFW: 6lbs 7oz
 L1 breech
 L2 fetal back R
 L3 unengaged
 L4 cephalic

 IE: 3cm, 80% effaced, st -1, (+)BOW, cephalic

 Latest Ultrasound (June 12, 2018) 39 2/7
weeks by LMP
• Single live intrauterine pregnancy
• Cephalic presentation
• 37 4/7 sonar weeks by BPD, HC and FL measurements
• Good cardiac and somatic activities
• EFW 6lbs 9oz by Hadlock and Warsof
• Appropriate for gestational age
• Left anterolateral placenta, grade III, no previa
• Adequate amniotic fluid (9.21cm)
• BPS 8/8
 Laboratories
CBC Result Normal Values
Hemoglobin 114 110-150 g/L
Hematocrit 0.34 0.38-0.47
RBC 3.70 4.00-5.50x10^12/L
WBC 8.5 5.00-10x10^9/L
Neutrophil 0.67 0.50-0.70
Lymphocyte 0.20 0.20-0.40
Eosinophil 0.03 0.00-0.05
Monocyte 0.09 0.00-0.09
Basophil 0.01 0.00-0.01
Platelet 348 150-400x10^9/L
Blood type A+
ADMITTING DIAGNOSIS

G3P2(2002) Pregnancy Uterine 40 1/7

weeks AOG by LMP, Cephalic in labor
Magbanua, Renita
• 32/M
• G1P0
• CC: increased blood pressure
• 6 hours prior to admission, patient had her scheduled PNCU and BP was noted to be
↑140/80 mmHg. Patient was then advised for NST and BP monitoring. NST was
reassuring and BP was 140/90 mmHg →130/90 mmHg. Patient was asked to come back
after 2 hours for reassessment.
• At the time of admission, after 3 hours, patient came in with BP 160/100
mmHg→140/90 mmHg after 15 mins, then 140/90 mmHg after an hour. Hence patient
was advised admission.
• (+) active fetal movements
• (-) watery vaginal discharge
• (-) vaginal bleeding
 PAST MEDICAL HISTORY
 (-) Hypertension
 (-) Diabetes Mellitus
 (-) Bronchial Asthma
 (-) Thyroid/ Cardiac disorder
 (-) Previous surgery
 (-) FDA

 FAMILY HISTORY
 (+) Hypertension- both sides
 (-) Diabetes Mellitus
 (+) Myocardial Infarction- maternal side
 (-) Bronchial Asthma
 (-) PTB
 (-) Cancer

 PERSONAL & SOCIAL HISTORY

 Non-smoker
 Non-alcoholic beverage drinker
 Teacher
 OB/GYNE HISTORY
 G1P0

MENSTRUAL HISTORY
Menarche: 13 years old
Interval: regular
Duration: 4-5 days
Amount: 2 pads/day, moderately soaked
Symptoms: (+) dysmenorrhea
LMP: Oct 4, 2017
AOG: 36 5/7 weeks by LMP
37 1/7 weeks by UTZ
EDC: July 11, 2018 by LMP

 Coitarche: 31
 # SP: 1
 (-) OCP use
 (-) Papsmear
OB Course:
1st PNCU: 5 weeks AOG w/ AP, total of >10 visits
8 weeks AOG- URTI (nasal catarrh & cough)- no meds given
20 weeks AOG- cough- no meds given
UTI- unrecalled antibiotics BID x 7 days

3rd trimester- unremarkable

Supplements: MTV (Prenat) 1 cap OD; Calcium (Calciumade) 1 cap OD

 PHYSICAL EXAMINATION
 BP 140/90 mmHg | HR 85 | RR 20 | T 36.5
 Ht 5’1” Wt 57 kg BMI 23.74
 Awake, ambulatory, not in cardiopulmonary distress
 Anicteric sclerae, pinkish palpebral conjunctivae
 Symmetrical chest expansion with clear breath
sounds
 Adynamic precordium with regular rate and rhythm
 Breasts symmetrical without lesions nor masses
 Gravid abdomen
 FH: 31 cm
 FHB: 136 bpm
 EFW: 5lbs 12oz
 L1 breech
 L2 fetal back R
 L3 unengaged
 L4 cephalic

 IE: 2cm, 50% effaced, st -1, (+) BOW, cephalic

 Latest Ultrasound (June 12, 2018) 39 2/7
weeks by LMP
• Single live intrauterine pregnancy
• Cephalic presentation
• 37 4/7 sonar weeks by BPD, HC and FL measurements
• Good cardiac and somatic activities
• EFW 6lbs 9oz by Hadlock and Warsof
• Appropriate for gestational age
• Left anterolateral placenta, grade III, no previa
• Adequate amniotic fluid (9.21cm)
• BPS 8/8
 Laboratories
CBC Result Normal Values
Hemoglobin 110-150 g/L
Hematocrit 0.38-0.47
RBC 4.00-5.50x10^12/L
WBC 5.00-10x10^9/L
Neutrophil 0.50-0.70
Lymphocyte 0.20-0.40
Eosinophil 0.00-0.05
Monocyte 0.00-0.09
Basophil 0.00-0.01
Platelet 150-400x10^9/L
Blood type O+
ADMITTING DIAGNOSIS

G1P0 Pregnancy Uterine 37 1/7 weeks

AOG by UTZ, 36 5/7 AOG by LMP,
Cephalic in labor, Gestational
Hypertension