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CLINICAL HISTORY

Date: January 17, 2014

Quevedo
Olivar
Principe
Torre
Santiago
Agbada

Informant: Patient
% Reliability: 75%

GENERAL DATA:
Adel, Rhia Ante, 34 years old, Gravida 4 Para 3 (3003), presently residing at #414
Magdiwang St., Saint Francis Village, Novaliches, Quezon City, admitted for the second time at
FEU-NRMF Medical Center on Janaury 17, 2014.
PATIENT'S PROFILE:
Birthdate: April 19, 1979
Birthplace: Quezon City
Status: Single
Religion: Roman Catholic

Occupation: none
Habits: 2.5 pack year-smoker,
non-alcoholic beverage drinker
Attitude: cooperative
Availability of relatives: near

CHIEF COMPLAINT: ruptured bag of waters


HISTORY OF PRESENT PREGNANCY
LMP: April 15, 2013
PMP: May 9, 2013

AOG : 39 weeks and 4 days by LMP


EDC: January 22, 2014

FIRST TRIMESTER
The patient experienced the usual signs and symptoms of pregnancy such as cessation of
menses and urinary frequency. She did not perform any self-pregnancy test. Because the patient
was not aware that she is pregnant, she admitted that she still continued smoking at that time. She
denies any exposure to trauma, accidents, major illnesses or exposure to toxic chemicals or
radiation. No medications taken, no consult done.
SECOND TRIMESTER
On the fourth month of missed period (July 2013), the patient performed a self-pregnancy
test which revealed a false negative result. Since the result was perceived as negative, the patient
did not consult until the sixth month of missed period (October 2013) at the FEU-NRMF Outpatient
Department. She also complained of a palpable mass on the right lower quadrant and the presence
of white vaginal discharge. No associated signs and symptoms such as dysuria, fever, nausea or
vomiting. Upon physical examination, the patients abdomen was globular, fundus occupied by
breech, with a fundic height of 26 cm. fetal back on the left, fetal small parts on the right, fetal heart
tones at 130s beats per minute best heard on the left lower quadrant. Speculum exam revealed
clean-looking cervix with yellowish non-foul smelling discharge. Internal exam showed a normallooking external genitalia, nulliparous introitus, vagina admits 2 fingers with ease, cervix was closed,
posterior, uneffaced. A repeat pregnancy test was also done which revelead a positive result. Her

assessment was Gravida 4 Para 3 (3003), Pregnancy Uterine 27 weeks, To consider vaginitis,
Previous Low Segment Cesarean Section III (1x due to cephalopelvic disproportion). Laboratory
tests requested were complete blood count, blood typing, Hepatitis B surface antigen, Hepatitis B
screening and 75-gram oral glucose challenge test. A transvaginal ultrasound was also requested.
However, all these tests were not done. Gram staining and wet smear of the cervicovaginal
discharge were also done. She was then prescribed with Multivitamins 1 tablet once a day, Ferrous
sulphate 1 tablet once a day, Calcium 1 tablet twice a day and Prenatal milk 1 glass once a day, all
of which she did not take regularly.
The next day, the patient came back with complaints such as mild colds, vaginal pruritus and
short uterine contractions felt 2-3 times in an hour associated with fetal movements. She also
brought the results of the Gram stain and wet smear of the cervicovaginal discharge which revealed
Nugents score of 1 with 30-50 pus cells/hpf, positive for yeast cells, negative for clue cells, positive
for fungal elements, negative for trichomonas species. Her assessment was Gravida 4 Para 3
(3003), Pregnancy Uterine 27 weeks, Threatened Preterm Labor, Vaginal Candidiasis, Previous Low
Segment Cesarean Section III (1x due to cephalopelvic disproportion), Pfannenstiel. She was then
prescribed with Clotrimazole (Canesten) 10mg/tablet, 1 vaginal tablet inserted at bedtime for 7
nights and Isoxuprine hydrochloride 10mg/tablet, 1 tablet three times a day, all of which she
completed. She was also advised to continue all the prenatal medications prescribed and to facilitate
all the laboratory tests requested. She was supposed to come back after 3 days, however the patient
was lost to follow-up. She denies any exposure to trauma, accidents, major illnesses or exposure to
toxic chemicals or radiation.
THIRD TRIMESTER
Subsequent check-ups were irregular as well as intake of previously prescribed prenatal
medications. She had a transbadominal ultrasound done on the eighth month of pregnancy
(December 2013) however, she cannot recall or retrieve its results. She denies any exposure to
trauma, accidents, major illnesses or exposure to toxic chemicals or radiation.
The present condition started three hours prior to admission, when the patient noticed
vaginal bleeding, minimal to moderate amount, no pad change. Thirty minutes prior to admission,
she noticed sudden watery vaginal discharge which prompted her to seek consult at a government
hospital. However, she was advised to transfer due to unavailability of blood. She transferred to
another government hospital but was denied admission due to unavailability of operating room. At
that time, she noted abdominal pain, specifically on the hypogastric area and passage of dark
greenish vaginal discharge perceived as meconium. The persistence of the above signs and
symptoms prompted the patient to seek consult at this institution where she was seen and was
subsequently admitted.
PAST MEDICAL HISTORY
The patient had the usual childhood diseases such as measles, mumps and chicken pox.
She is non-hypertensive, non-diabetic and non-asthmatic. Previous operations include Low Segment
Cesaren Section done three times in 1997, 1998 and 2007. She has no history of blood transfusion,
accidents, trauma, major illnesses or exposure to toxic chemicals or radiation.
FAMILY HISTORY
Father - age 52, deceased due to heart disease
Mother - age 51, alive; with asthma
Siblings - 3 sisters, all are alive and apparently healthy
She denies history of heredofamilial diseases such as hypertension, diabetes, asthma,
pulmonary tuberculosis, liver or kidney diseases.

PERSONAL AND SOCIAL HISTORY


The patient is the eldest among 4 siblings. She is a highschool graduate and she is presently
unemployed. She is in a live-in relationship with R.B. 39 years old, driver, for 7 years now. She is a
2.5 pack year-smoker, occasional alcoholic beverage drinker. She has no food preferences and has
no known allergies to food or medication.
REPRODUCTIVE HISTORY
A. Gynecologic History
The patient had her menarche at 12 years old which lasted for 5 days, moderate flow,
consumed 4 to 5 pads per day, moderately soaked and was associated with dysmenorrhea.
Subsequent menses were regular at 28 to 30 days interval lasting for 5 days, moderate flow,
consuming 3 to 5 pads per day, moderately soaked, associated with occasional dysmenorrhea. She
has no history of dyspareunia, postcoital bleeding and leukorrhea. No history of exposure to sexually
transmitted diseases. No Pap smear test done.
B. Obstetric History
The patient is Gravida 4 Para 3 (3003).
The first pregnancy was delivered to a term baby girl with a birth weight of 9 lbs. via Low
Segment Cesarean Section due to cephalopelvic disproportion in a private hospital, assisted by an
obstetrician. There were no fetomaternal complications noted. She is now 16 years old and is
apparently healthy.
The second pregnancy was delivered to a term baby boy with a birth weight of 8 lbs. via
Repeat Low Segment Cesarean Section, in a private hospital, assisted by an obstetrician. There
were no fetomaternal complications noted. He is now 15 years old and is apparently healthy.
The third pregnancy was delivered to a term baby boy with a birth weight of 9 lbs. via Repeat
Low Segment Cesarean Section, in a private hospital, assisted by an obstetrician. There were no
fetomaternal complications noted. He is now 6 years old and is apparently healthy.
The fourth pregnancy is the current pregnancy.
C. Method of Contraception
The patient used Oral Contraceptive Pills from 2003 to 2004.
D. Sexual History
The patient had her coitarche at the age of 22 years old and had a total of 5 sexual partners.
She does not know the number of sexual partners her partners had. She is presently in a
monogamous relationship.

REVIEW OF SYSTEMS
Constitutional: no fever, no chills, no weight loss
Hematology: no easy fatigability, no easy bruising
Central Nervous System: no seizures, no loss of consciousness
HEENT: no blurring of vision, no hearing loss, no tinnitus
Respiratory: no dyspnea, no cough, no colds, no apnea
Cardiovascular: no chest pain, no palpitation, no orthopnea
Gastrointestinal: no nausea, no vomiting, no constipation, no diarrhea
Genitourinary: no dysuria, no urgency, no frequency
Neuromuscular: no myalgia, no, arthralgia, no numbness

PHYSICAL EXAMINATION
General Survey: the patient is conscious, coherent, not in cardiorespiratory distress with the
following vital signs: BP = 110/80mmHg
PR = 84bpm RR = 18cpm Temp = 36.4C
HEENT: pale palpebral conjunctivae,
tonsillopharyngeal congestion

anicteric

sclerae,

no

nasoaural

discharge,

no

Neck: supple, no neck vein engorgement, no cervical lymphadenopathy


Chest: symmetrical chest expansion, no retractions, no lagging
Lungs: vesicular breath sounds, no wheezes, no crackles
Heart: adynamic precordium, normal rate, regular rhythm, no murmur
Abdomen: globularly enlarged, fundic height of 33 cm. fundus occupied by breech, fetal back on the
right, fetal small parts on the left, fetal heart tones at 140s beats perminute best heard on the right
lower quadrant
Extremities: no gross deformities, full and equal pulse, no edema
Speculum exam: clean-looking cervix with pooling ofdark greenish vaginal discharge
Internal exam: normal-looking external genitalia, nulliparous introitus, vagina admits 2 fingers with
ease, 2-3 cm. 50% effaced, ruptured bag of waters, cephalic, station -2

ASSESMENT: Gravida 4 Para 3 (3003)


Pregnancy Uterine 39 weeks and 4 days, cephalic, in beginning labor
Premature Rupture of Membranes x 30 minutes
Thickly Meconium Stained Amniotic Fluid
Previous Low Segment Cesarean Section III (1x due to cephalopelvic disproportion)

PLAN: Place on nothing per orem (NPO) temporarily


Intravenous fluid: D5LR 1 Liter for 8 hours
For Low Segment Cesarean Section IV with Bilateral Tubal Ligation
For Complete Blood Count and Urinalysis
Medications: Cefuroxime 1.5 gm TIV ( ) ANST after cord clamping
Metronidazole 500 mg TIV ( ) ANST
For blood transfusion of 3 units of packed red blood cells, properly typed and crossmatched
Refer

JIIC FLORA KATRINA M. RESCOBER

Department of Obstetrics and Gynecology