DE LA SALLE UNIVERSITY MEDICAL CENTER

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

CLINICAL HISTORY

GENERAL DATA
L.T., 23 years old, G1P0, married, Filipino, Roman Catholic, from Cavite, consulted the DLSUMC-ER on
February 10, 2021

CHIEF COMPLAINT
Labor pains

PAST MEDICAL/SURGICAL HISTORY

 Heart Disease - Mild Mitral Regurgitation
 Hypothyroidism (Maintained on 50 mcg OD)
 No history of allergy, asthma, diabetes mellitus, hypertension, seizure disorders, nor STI

FAMILY HISTORY
 No history of allergy, diabetes mellitus, asthma, heart disease, cancer, tuberculosis, hepatitis, multifetal
pregnancies nor congenital anomalies in the family

PERSONAL AND SOCIAL HISTORY

 Patient is a non-smoker, occasional alcoholic beverage drinker; Highschool graduate

MENSTRUAL HISTORY
The patient had her menarche at 13 years old. Her menses are regular that lasts 7 days. She reports
using up to 8 moderately soaked napkins a day with no dysmenorrhea.

GYNECOLOGICAL HISTORY
 No papsmear
 No history of infection, disease or surgery of the female reproductive tract

SEXUAL HISTORY
Patient had her first sexual contact at 21 years old with two (2) lifetime sexual partner. No post-coital
bleeding nor any other signs and symptoms associated with coitus.
CONTRACEPTIVE HISTORY
 None

HISTORY OF PRESENT PREGNANCY

LNMP = May 8-12, 2020
PMP = APRIL 3-5
Prenatal check up at the OPD = 11 times
Antenatal labs
TSH: 4.42 (0.30-4)
FT4: 4.09 (7-18)

2DED (7/7/2020)
The left ventricle is normal in dimension with adequate wall motion and normal systolic function
The left atrium, right atrium and right ventricle are normal
Normal mitral valve, aortic valve and pulmonic valve
There is no pericardial abnormality noted
IMPRESSION
Normal left ventricle
Mild mitral regurgitation
One hour prior to admission, patient noted regular contractions coming in every 3-5 minutes, lasting for 30-
50 seconds, moderate to strong in intensity. There was noted good fetal movement, no spotting or watery discharge
noted. Due to progression of uterine contractions patient consulted at the emergency room. Upon arrival at the ER,
she has uterine contractions every 2-3 minutes lasting for 30-60 seconds, moderate to strong in intensity. She has
stable vital signs. She has no cough, colds, fever, palpitation or difficulty of breathing. On IE, cervix was 4cm dilated,
60% effaced, intact bag of water, cephalic, station -2.

REVIEW OF SYSTEMS
o General: (-) weight loss, (-) poor activity, (-) loss of appetite
o Integument: (-) pruritus, (-) acne, (-) nail clubbing
o HEEN: (-) vision difficulties, (-) use of glasses, (-) lacrimation, (-) hearing difficulties, (-) ear pain, (-) ear
discharge, (-) frequent colds, (-) nasal discharge, (-) mouth sores, (-) epistaxis, (-) toothache
o Neck and Throat: (-) lymphadenopathy, (-) mass, (-) muscle stiffness, (-) muscle weakness, (-) frequent sore
throat
o Cardiovascular: (-) cyanosis, (-) fainting spells
o Respiratory: (-) cough, (-) dyspnea, (-) chest pain
o Gastrointestinal: (-) abdominal pain, (-) loose stool, (-) vomiting, (-) diarrhea, (-) constipation
o Genitourinary: (-) dysuria, (-) discharge
o Endocrine: (-) cold intolerance, (-) heat intolerance, (-) polydipsia, (-) polyuria (-) polyphagia
o Nervous/Behavioral: (-) weakness, (-) sleep problems, (-) seizures, (-) eating problems,
(-) mood/personality changes
o Musculoskeletal: (-) limitation of motion, (-) muscle pain, (-) joint pain, (-) edema
o Hematopoietic: (-) pallor, (-) bleeding, (-) easy bruisability

PHYSICAL EXAMINATION

GENERAL SURVEY
Patient is well developed, well nourished, conscious, coherent, oriented to place, person and time, in no
cardiorespiratory distress, appears her chronological age of 23 and ambulant.

VITAL SIGNS
BP = 110/80mmHg
HR = 82bpm
RR = 20cpm
Temp = 36.5°C

CHEST AND LUNGS Clear breath sounds

HEART Regular rate and rhythm with no murmur
ABDOMEN
The abdomen is symmetrical and globularly enlarged with flat umbilicus and grayish-white abdominal striae.
No prominent vessels, pulsations, scars, visible peristaltic movements, umbilical hernia nor tenderness noted. Fundic
height is 32cm.
LM 1 – soft nodular parts
LM 2 – fetal back on the right, small parts on the left
LM 3 – cephalic, not engaged
LM 4 – not performed
 Auscultation: FHT = 140bpm on the right lower quadrant

GENITALIA/CLINICAL PELVIMETRY
External genitalia grossly normal. Vagina is non-parous, cervix dilated to 4cms, 60% effaced, intact
membranes, cephalic, station -2. Noted mucoid bloody discharge per finger.