CASE STUDY

SUBMITTED BY : MIRANDA, Brylle F. AQUIPEL, Toney Anne M. CARITATIVO, Katrina D. HIPOL, Dae Diane C. MEDINA, Darlene Cae G.

PATIENTS PROFILE
Name: HARE, Laika Grace Madarang Age: 20 years old Birthdate: September 15, 1991 Birthplace: Sison, Pangasinan Address: Agat, Sison, Pangasinan Next of Kin: Elena Hare Educational Attainment: 3rd year college Attending Physician: Dr. Alice Salvador Date & Time Admitted: January 25, 2012/ 8: 30am Sex: Female Civil status: Single Religious Affiliation: Catholic Ethnic Group: Ilocano Contact No. : 09199786051 Relationship: Mother Nationality: Filipino Admitting Physician: Dr. Viado Room No.: 032 6

HEALTH HISTORY I. II. Chief Complaint: Labor pain History of Present Illness: 28 hours prior to admission, patient had hypogastric pains and lumbosacral pain. There was an also noted uterine contraction occurring at 2 minutes interval, 1 minute in duration, severe in intensity. No associated rupture of membranes, no noted vaginal discharge. Consultation was done where an IE revealed a posterior cervix, admits tip of finger. S + -1, CTE was also done which was normal. Few minutes prior to admission, a BPPS was done which revealed a grade 2 placenta and an EFW of 2.4 kg. There was also a cessation of abdominal pain. III. Past Medical History: Patient claimed to have no previous hospitalization and surgeries. IV. Prenatal History: Patient was cognizant of pregnancy at 5 weeks age of gestation due to amenorrhea. Pregnancy test was done at home revealing a (+) result. She had her prenatal check-up six times.

V.

Menstrual History: Patient had her menarche at 13 years old, 4 days duration, consuming 2-3 moderately soaked pads per day. She claimed to have dysmenorrhea and subsequent menses were irregular at 28 cycles for 6 days.

VI.

OB History: OB score: G1 Present pregnancy.

VII.

Gyne History: Patient had no gynecological illness in the past, (+) family planning, and (-) Pap smear.

VIII. Sexual History: Patient claimed that her 1st sexual contact was at the age of 16 years old, (+) bleeding, (+) dyspareunia. Subsequent contacts were comfortable, (-) bleeding, (+) dyspareunia. Claims to have 1 sexual partner. Last sexual contact was last November 2011. IX. Family History: No Hypertension, DM, CVP, Asthma, Twinning. X. Social & Environmental History: Patient is not smoking but she is drinking alcoholic beverages before pregnancy. She also claimed that she is gambling. She is living with her parents at Sison, Pangasinan.