Postpartum checkup and family planning

Script here.
NAME: Gemma Cruz AGE: 21 DATE: August 24, 2021
BIRTHPLACE: QC CIVIL STATUS: Married # OF YEARS RELIGION: Catholic

ADDRESS: MARRIED: 1
OCCUPATION: Housewife EDUCATION: NATIONALITY: Filipino
CC: POSTPARTUM CHECKUP, FAMILY PLANNING
HISTORY OF PRESENT ILLNESS:

● ONSET:
● LOCATION:
● DURATION:
● CHARACTERISTICS:
● ASSOCIATED:
● AGGRAVATING
● RELIEVING:
● TEMPORAL:
● SEVERITY:
● PREGNANCY TEST:
Breast feeding? Normal ba cycle?

● 3 weeks ago nanganak (21 days) no menses
●
ASSOCIATED SYMPTOMS: SA ROS DAW PO ITO IASK

ALWAYS CHECK FOR DANGER SIGNS OF PREGNANCY!
SYMPTOM 1 1. HEADACHE
● ONSET: 2. BLURRING OF VISION
● LOCATION: 3. PROLONGED VOMITING
● DURATION: 4. FEVER
● CHARACTERISTICS: 5. NONDEPENDENT EDEMA
● AGGRAVATING 6. HYPOGASTRIC PAIN
● ASSOCIATED: 7. DECREASED FETAL MOVEMENT
● RELIEVING 8. DYSURIA
● TEMPORAL 9. BLOODY VAGINAL DISCHARGE
● SEVERITY 10. WATERY VAGINAL DISCHARGE
OBSTETRIC TOTAL PAST PREGNANCY: 1 FULL TERM: PRETERM: 1 ABORTION: 0 ALIVE: OB SCORE:
HISTORY 0 1
G1P1 (0101)
DATE PREGNANCY LABORS PUERPERIUM
NOTES: Example: G1(2019) delivered to a live term baby boy/girl (BW:_) via NSD or via CS (indications, ex. d/t failure of induction), complications (ex. (+) preeclampsia)
1. G1(2021) Preterm girl, scheduled CS due to placenta previa
NOTES:
2.
NOTES:
3.
NOTES:
MENSTRUAL HISTORY SEXUAL HISTORY

MENARCHE 12 years old COITARCHE
INTERVAL Regular, 28-30 days NO. OF SEXUAL

PARTNERS
DURATION 3-4 days
POST-COITAL
AMOUNT 4 pads, regular, moderately soaked BLEEDING
SYMPTOMS none DYSPAREUNIA
CONTRACEPTIVES
USE
LMP November 20, 2020
OCCUPATION OF
PMP HUSBAND
AOG
FAMILY PLANNING METHOD
EDC
● none
Please show solution here: GYNECOLOGIC HISTORY (if needed):

AOG ●
EDC
PAST MEDICAL AND SURGICAL HISTORY FAMILY HISTORY

SURGERIES, none DM Mother
TRANSFUSION
HPN Father
OB & GYN Scheduled CS
PROCEDURES CANCER
HOSPITALIZATION Others:
IMMUNIZATION COVID-19 vaccine during pregnancy

(Childhood, Hepa B,
Covid)
COMORBIDS none
MEDICATIONS none
ALLERGIES none
SOCIAL HISTORY PREVIOUS PRENATAL CHECKUP

SMOKING none WHO
ALCOHOL none WHERE
COFFEE WHEN
DRUGS none FREQUENCY > 10x
DIET RESULTS Found placenta previa at 32wks; induction of labor at 36wks AOG
EXERCISE MEDICATIONS
REVIEW OF SYSTEMS:
GENERAL
SKIN, HAIR, NAILS
EYE
EAR
NOSE
MOUTH
CARDIO
PULMO
GASTROINTESTINAL
GENITOURINARY
HEMATOLOGY
NEUROLOGIC
ENDOCRINE
MUSCULOSKELETAL
FOCUSED PHYSICAL EXAM: (ASK PX TO VOID FIRST)

● GENERAL SURVEY ● ABDOMINAL
○ MENTAL STATUS: ○ INSPECT: flabby
■ AMBULATORY, NOT IN DISTRESS, conscious, coherent ■ 10 cm infraumbilical midline scar, dry well coaptated, no pus
○ BODY HABITUS: ■ AUSCULTATE:
● VITALS SIGN:
○ PERCUSS:
○ BP:110/80
○ PALPATE:Contracted uterus
○ HR: 70
● PELVIC
○ RR: 17
○ TEMP: 36.6 ○ INSPECTION OF EXTERNAL GENITALIA
○ O2 sat 98% ■ Normal lochial discharge- lochia serosa (minimal,
● ANTHROPOMETRIC DATA straw-colored non-foul)
○ HEIGHT: 1.5 M ○ SPECULUM EXAM
○ WEIGHT: 63 kg ■
○ BMI: 28, Obese
○ INTERNAL EXAM
Asia-Pacific ■ CERVIX
<18.5 = Underweight ■ UTERUS
18.5 - 22.9 = Normal ■ ADNEXA
23 - 24.9 = Overweight
■ CUL-DE-SAC
>/= 25 = Obese
■ BISHOP’S SCORE:
● Dilatation:
● SKIN, HAIR, NAILS:
● Effacement:
● HEENT:
○ INSPECT: ● Consistency:
○ PALPATE: ● Position:
○ PERCUSS: ● Station:
○ AUSCULTATE: ■ CLINICAL PELVIMETRY
● CARDIO: normal ● RECTAL EXAM
○ INSPECT: ○ INSPECT:
○ PALPATE: ○ PALPATE:
○ AUSCULTATE: ● RECTOVAGINAL EXAM
● RESPIRATORY: normal ○ PALPATE:
○ INSPECT:
○ PALPATE: ● EXTREMITIES
○ PERCUSS: ○ edema?
○ AUSCULTATE:
● BREAST:
○ INSPECT: symmetrical
○ PALPATE: no masses no tenderness, slight engorgement due to BF
○ PERCUSS:
○ AUSCULTATE:
SALIENT FEATURES
Script: We are presented with a 21 year old, G1P1(0101), who came in to consult for family planning. She gave birth 3 weeks ago through CS at 36 weeks due to placenta
previa.
______ of ___ duration, accompanied by_____, and positive?pregnancy test. On PE, pertinent PE would include ______. On speculum exam, the cervix was _______.
PERTINENT POSITIVE PERTINENT NEGATIVE
21 years old PE: Normal general survey, vital signs, cardio, respiratory, there is slight
CC: Gave birth 3 weeks ago - consult for family planning engorgement of the breast because she is breastfeeding.
No menses Abdominal exam 10 cm infraumbilical midline scar, dry well coapted, no pus and
G1P1 (0101) uterus is contracted as she only gave birth 3 weeks ago.
Previous preterm, CS at 36 wks - Placenta previa
FH HPN - Father
Menstrual history:
- Regularly menstruating
LMP was before her pregnancy and she is continuously breastfeeding her child.
G1P1 (0101) Post partum Day 21 status post LTCS1 secondary to placenta previa delivered Preterm to a live baby girl, 36 weeks AOG, Apgar score ___ Birthweight
___, pediatric aging ____, appropriate for gestational age
TENTATIVE DIAGNOSIS/ FINAL DIAGNOSIS: G1P1 (0101) Post partum Day 21 status post LTCS secondary to placenta previa delivered Preterm to a live baby
girl, 36 weeks AOG, Apgar score ___ Birthweight
BASIS FOR THE DIAGNOSIS:
DIFFERENTIAL DIAGNOSIS:
DIFFERENTIALS
RULE IN
RULE OUT
ANCILLARIES: TREATMENT/ PLANS AND FOLLOW UP DATE:

Please include rationale, pathophysio, and expected findings Please include pathophysio and expected findings
PNCU:
●
Prescription
●
Follow up
Family planning methods:
Calendar method
○ For regular cycles only
○ Subtract 14days from cycle length then subtract 5 days then add 4
days
LACTATION AMENORRHEA METHOD (LAM)

- Breastfeeding as birth control
- Will not 100% prevent pregnancy since there are conditions for this to be
effective
- 1. Lactational means exclusive breast feeding
- 2. Mother must not have menses yet = Amenorrhea means not
having menstrual bleeding - inhibition of pulsatile GnRH
- 3. Only used when baby is <6months
- Less effective if baby is older than 6 months
- First 6 months, she should not get pregnant. Lactation
amenorrhea is effective.
- <4HOURS INTERVAL/DAY
- <6 HOURS AT NIGHT
Sucking of nipples → Inc prolactin → suppression of gnrh -> dec FSH and LH →
suppress development and release of viable follicles and ovum
If patient wants to do mixed breastfeeding, we are left with natural

ways of family planning - calendar method (she has to wait for her
menses to occur again, around 6-8 weeks/ or a month if she isn’t
breastfeeding)
Calendar method:CALENDAR METHOD

- Recommended for women with regular cycles.
- FOR REGULAR CYCLE - Subtract 14 from the cycle length, then subtract 5
and add 4 to get range of fertile days
- FOR IRREGULAR CYCLE - this method is not recommended, however:
- Subtract 20 from the shortest cycle = 1st fertile day
- Subtract 10 from the longest cycle = last fertile day
- 11 longest cycle & 18 shortest cycle (another option)
- Range = day 4-26 fertile days,
- Day 1-3 mens. Day 27-30 okay for sexual intercourse
To ensure if patient is really regularly menstruating, must ask for PMP and PPMP if
there is some discrepancy between patient’s statement and LMP/PMP
I am Fertility
SPINBARKEITH KIOK
EGG WHIITE
Cervical mucus/Billings method
- Irregular cycle
- Dry days - early, infertile days G type of mucus
- No vaginal intercourse once there is clear, wet slippery, mucus secretion up
until 4th day from peak day of wetness
- Peakday of wetness: last day of slippery mucus
Recommended for irregular cycles of <26 or >36 days
Observation is usually done at end of the day or during the afternoon
DRY DAYS - G type of mucus
- Made up mostly of protein fibers = very hostile to sperm, does not facilitate
transport of sperm
- Opaque and flaky, sticky, non-elastic
WET DAYS - S type of mucus
- Strings of raw white, smooth, or slippery
- Feeling of fullness, softness, and swelling in the tissues around the opening
of the vagina
Refrain from vaginal intercourse once there is clear, wet, slippery mucus secretion
until after the 4th day from the peak day of wetness (peak day of wetness corresponds
to last day of wetness
BASAL BODY TEMPERATURE (BBT METHOD)

- Sleep needs to be at least 5hrs - get temp as soon as you wake up
- Lowest point in BBT seen within 1-2 days before LH surge
- Following ovulation, BBT generally increases by 0.2 to 0.5 degrees (due to
pregnanediol)
- Refrain from intercourse from the first day of menses until 3 days after the
temperature rise of 0.2 to 0.5 degrees
Artificial Contraceptives
Injectables
- 1 injection good for 3 months - DMPA - depot MPA
- If problem with compliance (daily OCP)
- 1-2 uses -> unscheduled bleeding or spotting (1 pad), hormones hindi pa nag
equilibrate
OCP
- If still breastfeeding, can't give estrogen containing bc it would dec amount of
breast milk; pathophysio uncertain
- First 2 months after birth, changes in pregnancy has not really subsided ->
hypercoagulable blood -> risk for clotting
- Use 2 months postpartum!
- Breastfeeding: Progestin only pills, MPA medroxyprogesterone acetate
- 1 pill once a day same day everyday (strict 24 hr interval)
- If missed, barrier method muna for 7 days
Medical eligibility criteria:
- Contraindications in using estrogen
- Severe liver disease
- Smoker
- Hx of stroke, MI, DVT, PE
- HTN, smoker b
- Undiagnosed breast mass
IUD - mirena system
Barrier method (condom)
ADMITTING ORDER - Admit Diet Monitor Investigation/Intervention Therapeutics
ADMIT
DIAGNOSIS
CONDITION
VITALS
ACTIVITY
NURSING ORDER
DIET
IV FLUIDS
MEDICATIONS
LABS
CALL HO
CARES Notes:
We had a case of a 21-yr old G1P1 (0101) who came in to consult about family planning. She had just given birth to a live preterm baby at 36 weeks AOG via CS due
to placenta previa. The menstrual history, such as the regularity of menses (LMP and PMP) and the interval before she got pregnant should be asked, as well as the
previous family planning method used and if she plans to have her baby exclusively breastfed. During the PE, it was important to check the size of the uterus and if
it was still contracting or not in order to avoid late postpartum hemorrhage. Lactation Amenorrhea Method (LAM) was advised and this can only be done if the baby
is less than 6 months of age. The interval should not be longer than 4 hours during the day and 6 hours during the night. The principle behind this method on how
breastfeeding can prevent fertilization or conception is through the release of prolactin during nipple suckling or stimulation which inhibits the pulsatile release of
GnRH causing a decrease in FSH and LH, suppressing the development and release of viable follicle and ovum.
If the patient tells you that she will not be continuing breastfeeding because she is planning to go back to work, calendar method will be advised. The basis for this
is subtracting 14 days from the regular duration of the cycle (estimate date of ovulation), then subtracting 5 days (to account for early ovulation) and adding 4 days
(to account for late ovulation).
■ 14-5 = 9
■ 14+4 = 18
■ 9-18 days (fertile days) - We advise the patient to not have sexual intercourse if no desire to get pregnant
If irregularly menstruating, and the longest cycle is 36 days and the shortest cycle is 24 days, we get the longest cycle and subtract it by 10, and get the shortest
cycle and subtract it by 20, so in this case we advise the patient not to have sexual intercourse on days 4-26.
We can also advise the patient to do the Cervical Mucus or Billing’s Method by monitoring the secretions from the vagina. Infertile/early phase will show an opaque
and flaky, not as slippery, and not that elastic vaginal mucus discharge, while ovulatory phase will show spinnbarkeit, smooth, slippery, distinct wet feeling (this
will tell you she is fertile) vaginal mucus discharge. We can also do the BBT by checking for the basal body temperature upon waking up. If she is ovulating, there
will be an increase in BBT by 0.2-0.5 degrees due to pregnanediol.
● Calendar Method - Irreg cycle
○ Longest cycle → subtract 10
○ Shortest cycle → subtract 20
○ Example if 36 and 24 = 4-26 (no sexual activity)
If a patient asks for an artificial method?
Artificial contraception like condom (barrier method)?
- Others:
- OCP
- Estrogen containing OCP should not be given to breastfeeding mothers (reduce amount of breastmilk) and to those 2 months postpartum
(blood is still hypercoagulable → has not returned to prepregnant state → at risk for blood clots)
- Precaution: Make sure 2 mos post partum to make sure changes go back to pre-preg and not hypercoagulable state anymore
- If breastfeeding → give progesterone-only or progestin pills ONLY
- Ideally, the pill should be started on day 1 of menses (1 pill OD) → same time! Very strict with the 24-hour interval (for effectivity)→ if not
done the right way, there will be body adjustments → spotting (so what she can use at this time is barrier/condom muna)
- Before prescribing OCP → go over the eligibility criteria
- Severe liver disease
- History of stroke
- DVT
- Pulmonary embolism
- Heavy smoker
- Hypertension
- Undiagnosed breast mass (no work ups done yet)
- Just give progesterone or use barrier method
- Injectables
- Advantage: need 1 injection and contraception is good for 3 months, for those with compliance problems
- Disadvantage: Unscheduled bleeding (spotting) → body is adjusting → reassure patient that it will be okay → observe unless bleeding is
heavy
General Data
ACT: Introduce that your part of the medical team, like “kasama po ako ng residente…” (to build rapport!)
No contact number for RMG!!!
Name: Theresa Luna (lol) Age: 41 Birthday: Address: *skip parts cos this is an emergency*
Interviewing the husband
Civil Status: # of years married: Nationality:
Education: Occupation: Religion:
Chief Complaint: Comments/Suggestions

Profuse vaginal bleeding
HPI
RMG Notes: concentrate on the CC during the HPI
DO NOT jump on other parts
Pregnant/suspicious of Amenorrhea, Pain, Discharge and Bleeding Prenatal/follow-up: Pt was brought in

preg: via ambulance
Onset Sa lying in, after delivery AOG
● LMP (then compute simula
AOG stat!)
Where Skip sexual and
● Had PT, how many Location
times, result menstrual hx
saan
● Presumptive symptoms When last ff
○ Morning sickness Duration
(6-18) tagal/kailan How many
○ Idiosyncrasies of
taste and smell Character Weight gain
○ Fatigue hapdi/hilab
dami/kulay
○ Urinary frequency, Assessment
nocturia (1st & 3rd
trimester) Assoc 6 hours prolonged labor; Patient is
Other body
Labs & Results
brought now via ambulance from the
○ Amenorrhea parts/ Lying-in clinic to hospital
○ Breast engorgement UTZ: CRL
○ Skin changes
Aggrav
○ Increased temp (6) activity If abnormal labs
○ Quickening (P-18-20;
M-16-18) Allev Present
● Probable signs meds/rest Condition
○ Abdominal Danger Signs
enlargement (12) Rad
Contractions (28)
Fetal Mvmt (16/18)
○ Braxton Hicks (28) Back etc
Signs of labor: ● UTZ: CRL (12), AOG, location of fetus, placenta

Tempo
● May nararamdaman na po
● If abnormal labs: Ask what was advised,
bang contractions (o
paninigas ng tiyan) prescription, intervention
● Gaano po katagal yung Sev
contraction and gaano 1-10 10 Danger Signs (for Prenatal Check up)
katagal yung pagitan ng 1. Headache
dalawang contractions? 2. Blurring of vision
If pregnancy was not mentioned try to connect with the
● Tetanic in Abruptio Placenta 3. Persistent vomiting
symptoms with pregnancy e.g. “nasabi niyo po na masakit
● Preterm Labor - ≥4 every 20
ang puson sumasakit din po ba ito tuwing nireregla kayo, 4. Fever and chill
minutes or ≥8 in 60 minutes
kailan last regla, nakapag-pregnancy test na po ba kayo?” 5. Nondependent Edema (hands, periorbital)
6. Dec fetal movement (16/18)
7. Abdominal pain (Epi/RUQ/Hypogastric)
8. Dysuria
9. Wateryvaginal discharge
10. Bloody vaginal discharge
LMP: Comments/Suggestions
PMP:
AOG (if ever):
MIDAS Menarche
*no na if preggy* Interval
*If TERM preg: focused hx Duration
does NOT include MIDAS Amount
na (“Your patient has big Symptoms
tummy, who cares of
menarche”)
OB Hx G: P: TPAL:
If Pregnant AOG: EDC:
Date (M/Y) Live Term/Preterm Sex & BW NSD/CS & Why Where Complications
2015 Term NSD none
2nd NSD none
3rd NSD none
Personal/Social/Past Medical Hx Comments/Suggestions
Sexual hx Coitarche *skip*

*ask consent first* # of Partners
*if coitarche is after Job of partners
wedding, don’t ask Last sexual contact
#partners Post Coital bleeding
Dyspareunia
Family Planning
Past Medical hx Comorbids (HTN/DM/Thyroid) (-) HPN, DM, thyroid disease Ask if with HPN, Asthma -
Medications Taking Vitamins because some uterotonics are
If DM mommy: Allergies C/I in hypertensive and
Kamusta monitoring Surgeries (naoperahan) asthmatic patients, eg.
mo ng sugar? Transfusions ● PGs (eg.
Nasusunod nyo po ba Hospitalizations Carboprost) - C/I in
yung diet na inadvise Immunizations HPN, asthma
sainyo? ● Flu ● Ergot alkaloids (eg.
Di po kayo ● Tdap Methergine,
nakakamiss ng insulin ● HPV Methylergonovine) -
nyo? ● COVID C/I in HPN
Prev Prenatal Check up ● Carbetocin - C/I in
Ask dose, ● Where HPN, CV disease
compliance, ● When last ff like CAD
frequency OD or BID ● How many
● Weight gain
● Assessment
● Labs & Results
● UTZ: CRL (12), AOG,
location of fetus,
placenta
● If abnormal labs: Ask
what was advised,
prescription,
intervention
Personal & Social hx Smoking *skip*

Alcohol
Drugs
Diet (usual na kinakain)
Exercise
Family hx DM *skip*
HTN
Cancer
Thyroid disease
Asthma
Blood dyscrasia
Seizure
Heart disease
Review of Systems Comments/Suggestions
*OMIT some of these if already asked in HPI* *skip*

General () Weight changes, () Changes in appetite, () Fever, () Chills, () Sleep Changes,
HEENT () Headache, () Blurring of Vision
Cardio () Palpitations, () Chest pain
Pulmo () Cough, () Colds, () Dyspnea
GI () Vomiting, () Abdominal pain, () Dec Fetal Movement, () Bowel changes, () Constipation, () Diarrhea, ()
Hematochezia/ Melena
GU () Dysuria, () Urinary frequency, () Nocturia, () Dribbling of urine kumpleto pag-ihi
Hematologic () Easy bruising
Neurologic () Headache, () Seizure kombulsyon
Endocrine () Polydipsia thirst, () Polyuria, () Polyphagia gutom, () Heat intolerance, () Cold intolerance
MSK () Malaise panghihina, () Cramp
Extremities () Edema (nondependent), () Edema (dependent), () tremors
10 Danger Signs (for

Prenatal Check up)
1. Headache
2. Blurring of vision
3. Persistent vomiting
4. Fever and chill
5. Nondependent
Edema (hands,
periorbital)
6. Dec fetal movement
7. Hypogastric pain
8. Dysuria
9. Water vaginal
discharge
10. Bloody vaginal
discharge
Physical Exam Comments/Suggestions

ASK PATIENT TO URINATE FIRST
TCL: State PE in this way always: “I will check for…”
TCL: Say “I” not “we”
General Mental Status Conscious coherent stretcher borne

Weight
● Pre-pregnancy weight (kg)
● Preg/current weight (lb)
Height
BMI (pre-pregnancy)
Vitals BP (140/90; Sev - 160/110) BP 90/60

Gestational HTN: ≥140/90 mmHg after 20 weeks; HR 130
returns to normal by 12 weeks postpartum
Preeclampsia: ≥140/90 mmHg after 20 weeks on
T 36.2
2 occasions at least 4 hours apart with proteinuria RR 23
Chronic HTN: ≥140/90 mmHg before pregnancy
or before 20 weeks; persistent after 12 weeks
postpartum
Treat if BP reaches 160/110 mmHg
HR
RR
Temp
HEENT Conjunctiva Pale palpebral conjunctiva

Sclera Anicteric sclera
Exophthalmos
Nasal discharge
Enlarged Thyroid/neck mass
Cervical Lymph nodes
Posterior Pharyngeal Wall
Cardio Precordium Dynamic precordium

Apex Beat *don’t look for apex beat, etc na*
Heaves
Lifts
Thrills
Murmurs
Respi Chest Expansion Symmetrical *skip*

Tactile fremiti
Resonant to percussion
Clear Breath sounds
Wheezes
Crackles
Breast *ask for consent first* *skip*

Inspection
● Symmetry
● Gross lesion
● Skin dimpling
Palpation
● Mass
● Tenderness
● Nipple discharge
● Lymphadenopathies (axillary,
parasternal, supraclavicular)
Abdomen Inspection Fundic height 1cm above umbilicus Assessment of uterine
Inspection ● Shape tone and size
Auscultation ● Scar *no na if no hx of surgery* Uterus sometimes relaxed, sometimes contracted Inspection of placenta
Palpation (Mcburney, Pfannenstiel/ Suprapubic ● Uterus soft and boggy Inspection of uterus,
Percusion transverse incision, Midline vertical
cervix, and vagin
incision)
Palpation - mass/tenderness
Fundic Ht (12,16,20) Rule out possible causes:
Tone
● Uterus soft and
boggy, flaccid and
relaxed (uterine
atony)
● If uterus is not
palpable in the
abdominal or
hypogastric area
anymore (uterine
inversion)
Tissue
● Retained
placental
Leopold’s (28) cotyledons inside
● LM1 (Fundic grip) uterus (missing
● LM2 (Umbilical grip) cotyledons)
● LM3 (Pawlik’s grip)
● LM4 (Pelvic grip) (37)
● Ask if pt had
placenta previa
Uterine contractions (28-Braxton/37) on this pregnancy,
● Mild/mod/severe
● Duration
check for adhered
● Freq (“occurring every __”) placenta in
● Tetanic in Abruptio Placenta uterus, or do UTZ
● Preterm Labor - ≥4 every 20 minutes or ≥8 later if with
in 60 minutes
intraplacental
Auscultation - heart tones venous lakes,
Fetal Heart Tone (6, 10, 18-20) loss of
retroplacental
Auscultation/ Bowel sounds hypoechoic zone
(placenta
If UTI:
● Percuss for CVA TENDERNESS - in
accreta/increta/
flank/lower back area percreta)
Trauma
If Abruptio placenta ● Uterine
● Presence of Abdominal tenderness,
Mass/Tenderness hypotension,
increasing
abdominal girth,
change in uterine
shape (uterine
rupture)
● Vulvovaginal and
cervical area -
any Lacerations
or Hematomas
Thrombin
● Hx of bleeding
disorder, past
easy bruising,
mucosal bleeding,
hematomas, Fam
hx of bleeding
disorders
(coagulopathies)
Pelvic External Genitalia Moderate to profuse vaginal bleeding Any lacerations?

● Inspection (Hair pattern, Lesions,
Erythema, Discharge/Bleeding)
● Palpation (mass, inguinal
lymphadenopathy) (+) 1st degree laceration
Speculum (no need to be done in F. check-ups,

unless CC is vaginal discharge, pruritus, watery vag
discharge as in ROM)
● Cervix = Violaceous/pink, smooth, discharge,
erythema, bleeding per os
● Vaginal wall = violaceous or pink
● PPROM
○ Pooling of amniotic fluid in the cul-de-sac
○ clear fluid flowing from the cervix
○ malodorous discharge
■ If no pooling or no clear fluid coming out, ask
patient to do Valsalva maneuver and see if
there would be passing of fluid
Internal (NO in Previa)

● Cervix + cervical motion
tenderness
○ 1st CHECKUP: Long, Soft, closed
○ In Labor
■ Cervical dilatation ≥3 cm
■ Cervical effacement of >80%
■ To check for cervical dilatation =
We should NOT palpate on the
cervical os cos might stimulate
contractions. Instead, palpate the
fornices and check the LENGTH.
Cos if long (uneffaced), probably
also closed os
○ 37 weeks onwards do IE
■ To check for soft, long,
dilatation, effacement,
presentation, station, BOW
● Uterus
○ Don’t check for ante-/retroversion,
mobility
○ Just check for SIZE
■ Slightly enlarged = 8wks (9-10wks
LNR)
■ At umbilicus = 20 wks AOG
■ Midway (accdg to TCL): 12 wks
AOG
○ (Tenderness in abruptio placenta)
● Adnexa (if possible; only until 12 wks)
● Cul-de-Sac & Fornices
○ Ectopic Pregnancy - Deep/Bulging if
ruptured
Bishop
Pelvimetry
● Inlet:
○ Measure diagonal conjugate (N: >11.5cm)
○ Sacral promontory (N: not accessible)
○ Engaged head?
○ Muller Hillis maneuver (station 0)
● Midpelvis:
○ Ischial spines (N: not prominent)
○ Pelvic sidewalls (N: Divergent/ NOT
convergent)
○ Sacrum curved
● Outlet:
○ Sub-pubic arch wide >90 degrees
○ Bituberous diameter >8cm (wider than fist)
● If abnormal findings: contracted uterus
Rectal PID, Endometriosis, Endometrioma
Extremities Pulses full and equal in all extremities Pulses 130, full
*don’t forget this if DTR
LNR ● Hypothyroidism - woltman’s sign
● Woltman sign is defined as delayed relaxation
phase of an elicited deep tendon reflex (achilles
tendon)
○ delayed muscle relaxation has been postulated
to be a result of decreased myosin ATPase
activity and decreased rate of reaccumulation
of calcium in the sarcoplasmic reticulum
Clinical Impression Comments/Suggestions

TCL: “I don’t want to hear t/c anymore. It doesn’t sound nice”
So example: G1P0 Early pregnancy
IF term: ADD cephalic, not in labor
G4P4 (4004), postpartum hemorrhage secondary to uterine atony,

hypovolemic shock
Subjective salients Objective salients Comments/Suggestions
(PERTINENT only to clinical impression) (PERTINENT only to clinical impression)
CC: dinugo pagkatapos manganak 90/60 RMG: What if in PE, you
6 hrs of labor HR 130 tachycardic; pulse 130 were not able to palpate
RR 23 cpm tachypneic for the uterus? What is
T 36.2 afebrile your diagnosis?
Pale palpebral conjunctivae ● Uterine inversion
Dynamic precordium
Mod to profuse vaginal bleeding
Uterus sometimes soft and boggy, sometimes
contracted
Differentials Comments/Suggestions
Ddx 1
Manifestations
Why Rule In Ddx:
Why Rule Out
Ancillaries
Management
RULE IN RULE OUT
● ●
Ddx 2
Manifestations
Why Rule In Ddx:
Why Rule Out
Ancillaries
Management RULE IN RULE OUT
● ●
Ddx 3
Manifestations
Why Rule In Ddx:
Why Rule Out
Ancillaries
Ddx:
RULE IN RULE OUT
Management Comments/
Suggestions
Ancillaries For Baseline ABCs first Check presence of

● CBC (N in preg: ≤14,000-16,000 Assessment: check hemodynamic status of patient retained placental
WBC) Breathing: Give O2 fragments
● Blood Typing (and of partner) Circulation: IV access and give crystalloids and
● Urinalysis
consider giving fresh whole blood kasi
● FBS
● HIV (3rd trim) hypovolemic shock (as volume resuscitation)
● HBSAG (3rd trim)
● VDRL/RPR (3rd trim) Volume Resuscitation
Ultrasound - Secure at least two large-bore IV lines
● Ectopic - Ring of Fire so:
● H-mole - 1st IV line: crystalloid w/
○ Complete - Snowstorm oxytocin can be continued
○ Incomplete - Thickened
multicystic placenta with fetal simultaneously with
tissue - 2nd IV line: Fresh Whole Blood
(keep heplock closed muna
BPP and Congenital Anomaly Scan while no blood unit yet)
(24 weeks AOG) - Begin volume resuscitation with rapid
intravenous infusion of crystalloid
- Naka fluids kasi resuscitation for volume
loss!!!
- Reserve 3-4 units fresh whole blood
(RMG: this # of units is fine with me)
Labs
● CBC - to check severity of blood loss; we

expect low Hgb and Hct in hypovolemic
shock
● Blood type and crossmatching -
needed for blood transfusion
● PT PTT - to check for coagulation status
and rule out coagulopathies
Treatment 1st trimester Step by step management for uterine atony

HPN in preg ● Folic Acid - .4mg/4mg (1 month prior to
Aspirin
● TCL: stock dose/for pt pregnancy - 14 wks) 1st: Uterine massage + 1st line Uterotonics
with HPN: 80mg (for ● Multivitamins 1 tab OD (Oxytocin along with Methylergonovine
TCL) 150 for other 2nd trimester
doctors maleate)
● TCL: Start on after 1s ● Ferrous Sulfate - 30 mg/day
trimester (best time) ● Multivitamins 1 tab OD
Ca supplement ● Calcium carbonate/Milk ● Uterine massage
● to prevent chronic HPN ○ Massage at the fundus near the
to progress ino
preeclampsia 24-34 weeks uterotubal junction since that is
● Betamethasone 12 mg given IM 24 hours where pacemaker of uterus is
GDM
● Monitor 2 weeks if diet apart for 2 doses ● Uterotonics
and exercise can control ● Dexamethasone 6 mg given IM every 12 ○ To decrease the bleeding
sugar. If not, prescribe hours apart for 4 doses
insulin
C/I
24-32 weeks
● MgSO4 - upto 32 wks only
Oxytocin IV 20
● IV (4-1): 4g slow IV push via infusion
pump for 20-30 mins then 1-2 g/hr for 24 units/L in constant
hours or until delivery whichever comes infusion
first
● IM (4-5-5): 4g slow IV push via infusion Methylergonovine Hypertension
pump + 5g IM on each buttock then 5g maleate
IM alternating per buttock 4 hours apart
IF FAIL →
2nd: Ask for help. Do Bimanual compression +

2nd line Uterotonics (Carboprost)
● Bimanual compression
○ One hand is over the abdomen
pushing down the uterus, while
one hand is inside the vagina in
fist position, kneading the
uterine anterior wall thru the
anterior vaginal wall; So uterus
is compressed between two
hands
● Uterotonics
○ 2nd line
C/I
Carboprost 250 ug Hypertension

IM Asthma
Amniotic fluid
embolism
IF FAIL →
3rd: Exhaust and use all other uterotonics

available, as long as not contraindicated to
patient
● Other uterotonics
C/I
Carbetocin Hypertension
Vascular dse (CAD)
Hypersensitivity
Misoprostol
(PGE1)
Dinoprostone Hypotension
(PGE2)
IF FAIL →
4th: Decide if patient wants future pregnancy

or not
● Hysterectomy (if undesirous of next

pregnancy
○ The BEST option; If patient
already wants to have ligation -
Do hysterectomy already (the
main reason is to prevent
maternal death)
○ Subtotal Hysterectomy - Best
management for uncontrollable
bleeding because of the shorter
time span. Can be done in
15-30 minutes. Except for
placenta Accreta (go for total
hysterectomy in this case)
○ Total Hysterectomy - longer
procedure → more bleeding
because the uterus is still
contracting; consider if there is a
concomitant placenta accreta
● Compression sutures (if desires future
pregnancy)
○ B lynch and cho compression
suture (take longer time and not
a guarantee that can stop
bleeding so best management
is hysterectomy)
*Uterine packing - not effective*
Follow-up schedule Advice to watch out for danger signs RMG: Weight of this
of pregnancy baby should have been
asked
Advice for ff-up:
● Normal Pregnancy PE start with VS and
○ <28 weeks - straight to pelvic exam
monthly
○ 28-36 weeks - Know cause of PPH to
every 2 weeks treat it immediately!
○ >36 weeks - every
week
● High-risk preg
○ More frequently
○ Every 1-2 week
intervals
Admitting Orders Comments/

Suggestions
Admission date - August 24, 2021 10:00 AM

Name - E.A.
Age - 34 yo G1P0 7-8 wks AOG
Diagnosis - G1P0 Acute Abdomen secondary to Ectopic
Pregnancy, 7-8 weeks, ruptured
Admit - Direct to OR
Diet - NPO
Activity - Maintain on bedrest
Monitor - Monitor HR, RR, Temp, O2 sat every hour
Ins and Outs - Monitor input and output every 8 hours
IV Fluid - Establish 2 large-bore IV access to infuse 1L PNSS to
run at rate 8mL/min and the other for possible blood transfusion
Investigations - Request CBC, blood typing, crossmatching
Therapeutics - Exploratory laparotomy possible salpingectomy
Call HO - Inform attending physician of admission
Inform physician ROD and IOD
Refer accordingly
CARES Notes
CLERK CARES COMMENTS:

● A lot was omitted in Hx cos patient is emergency
● Focused PE for this case = VS, Pelvic exam
● Look also for lacerations in the cervix, birth canal, retained placental tissues, uterine inversion, coagulopathies
● Ask for consent, when hysterectomy is warranted
TBM CARES COMMENTS:

● When the pt was stabilized, were the other parts of the Hx asked?
○ No. But in actual practice, we need to follow-up and ask once stabilized.
○ For Moore, okay to go back and ask the missing info, if there’s still time after discussion of case.
● Was the info asked about saan nanganak, what transpired
○ Usually in lying in centers, they don’t give oxytocin doon. They are also scared of the consequences of giving
oxytocin (eg. uteroplacental insufficiency). Usually kasi, if di nababantayan, napapablis ang rate → uterine
muscle relaxation → uterine atony
● Initial measures → put your hand on top of the abdomen, feel consistency of uterus →
○ If (+) soft boggy uterus → manage as uterine atony
○ If contracted → get retractor, speculum → check for cervical and vaginal lacerations
● Uterine atony
○ Uterine massage + uterotonics
○ Bimanual compression + 2nd line uterotonics
○ Exhaust all the uterotonics
○ Hysterectomy
● Risk factor for uterine Atony in this patient = Multiparous
● I agree with your faci. If multiparous patient, early on they are already primed/counseled in prenatal period for what
complications there could be like uterine atony. They prepare the blood units, and ask mom what she would like to be
managed with, if in case uterine atony and cannot be relieved with uterotonics -- B lynch, or hysterectomy.
○ Help patient in decision making. 41 yo, multigravid. = Hysterectomy is best
● Should we remove the ovaries at this time?
○ No. To prevent early surgical menopause. Consequences: Mood swings, Early osteoporosis, Vascular
diseases
● Should we remove the fallopian tube?
○ Yes. To reduce the risk of ovarian CA
○ Serous Tubal Intraepith Carcinoma
■ P53, BRCA1, BRCA2
● Ask also for the risk factors that may have caused uterine atony in the patient
○ OB Hx: the weight of the baby
● In such emergency cases as this, it is okay to do HPI, then jump to V/S then Pelvic exam
Extra sample case by Doc RMG from real experience/ his patient last February 2020:
● G1P0 underwent CS for fetal distress

● Chinese couple
● Gave birth to live BB girl
● Uterus also found: (+) posterior myoma 8x7cm and (+) ant. Myoma 4x5cm
● After suturing the 1st layer, the uterus doesn’t like to contract.
● Doc’s management:
○ Oxytocin given 20 units 1L and Methergine 2 doses (1 IV, 1 IM) → fail →
○ 3 doses of Carboprost (Carboprost x 15 mins → Carboprost x 15 mins → Carboprost) → fail →
● 2 L of blood loss already
○ FWB was given
○ BP went up to 100/70 (normal), but PR 120 (really elevated)
● Q: What should be your next management?
○ Hysterectomy
■ Because there’s failure of uterotonic and compression management, and because there are 2 large
sized myomas already
● Q: But the patient (wife) does not consent for hysterectomy, because her 1st baby is a girl. They wanted a son in
Chinese. What will be your next step?
○ Ask consent from the husband. And call someone who can speak Chinese.
■ RMG: Luckily our chief can speak Cantonese. The situation was explained to him, and also the 2.5
L blood loss was emphasized to him, pointing to imminent death if not forgo with hysterectomy.
Fortunately, the husband consented to do hysterectomy!
● Q: However, though husband insisted on wife for hysterectomy, wife still doesn’t want it. What is you next step?
○ Forego with hysterectomy!
○ Because even if Principle of Autonomy outweighs Principle of Beneficence, this is a matter of life and death.
■ You will not be sued/ your case will be stronger because you are saving a life, and the father is
■ It’s better to save the mother and then remove uterus, than mother died and by then no more
uterus.
○ Also may consult medico-legal officer
● RMG: Actually now, the couple thanks me, we’re close, etc. :))
GDM/Overt DM Algorithm
Bishop Scoring
Fetal Growth/IUGR
TSH Thyroid Labs

HEADSSSS
Maternal Weight Gain

Twin Pregnancy
c) abnormal weight gain
○ faster than expected; normally 1lb/wk during 2nd & 3rd trimester
HPI Script Reference
SCRIPT
INTRO AND GEN DATA

● Good afternoon, ako po si, clinical clerk ____. Narito po ako para kunin ang history ninyo.
● Ano po ang kumpletong pangalan ninyo? Ano po ang gusto nyong itawag ko po sayo?
● Ilang taon na po kayo?
● Saan po kayo nakatira?
● Ano po ang inyong trabaho?
● Married or single?
○ Ilang taon na po kayo kasal?
● May anak na po ba?
● Ano po ang inyong nationality?
● inyong relihiyon?
CC:
● Ano po ang dahilan bakit kayo nagpakonsulta ngayon?
HPI:
MISSED MENSES:
● Kelan ba ang huling regla mo? Ito ba yung normal na usual na regla mo, or napansin mong mas kaunti?
● First time ba to na nagmissed period ka?
○ If hindi: gano katagal kang hindi dinatnan noon? Hindi ka nagpacheck up noon?
● Regular ka talaga bwan bwan?
● May sexual contact ka ba nung nakaraan? Gumamit ka ba ng contraception noon?
● Symptoms of early pregnancy:
○ Nahihilo? Nagsusuka? Parang nasususka? Sinisikmura? Ihi ng ihi? Yung dede mo ba nararamdaman
mong medyo masakit?
● Nasubukan mo na ba magpregnancy test?
● Wala ka bang discharges ngayon, na malansa, mabaho? Hindi makati ang pwerta?
If Gyne:
● Hindi ka ba nastress nitong mga nakaraang araw? Hindi ka biglang nag exercise ng todo todo? Wala ka
namang biglang weight gain or weight loss? Hindi ka madaling lamigin or mainitan? Walang pakiramdam na
laging pagod? Palpitations?
● Wala kang nararamdamang masakit sa may puson? Nakakapang bukol? Or nararamdamang mabigat?
● May tinatake po ba kayong mga gamot?
PRENATAL CHECK UP
● Pang-ilang pre-natal check up na po ninyo ito? Yung mga dati ay dito din po sa UST?
● Wala naman po kayong kakaibang nararamdaman mula nung nagcheck up kayo nung nakakaraan?
● Signs of labor:
○ May nararamdaman na po bang contractions (o paninigas ng tiyan)? Gaano po katagal yung
contraction and gaano katagal yung pagitan ng dalawang contractions?
● 10 danger signs of pregnancy:
○ Wala ka namang papankit ng ulo?
■ Tuloy-tuloy o nawawala? May iniinom po bang gamot?
○ Hindi ka naman Nahilo?
○ Walang problema sa paningin?
○ Walang biglang paghilab ng tyan? Hindi po naninigas ang tyan?
○ Hindi mahirap ang pag ihi?
○ Hindi ka dinudugo
○ Walang kahit anong lumalabas sa puwerta?
○ Hindi naman po kayo nilagnat nitong mga nakaraan?
○ Di nyo napansin na may pamamanas sa kamay, braso at mukha?
○ Magalaw po ba si baby?
○ Ngayon po kamusta kayo?
If DM mommy:
● Kamusta monitoring mo ng sugar? Nasusunod nyo po ba yung diet na inadvise sainyo?
● Di po kayo nakakamiss ng insulin nyo?
ABDOMINAL PAIN
● Onset: Kelan po nagsimula? First time lang ho ba yan? (if pabalik balik, ask kung kelan nagsimula talaga)
● Location: Banda saan po? Sa bandang taas ho wala? Dyan lang talaga sa baba? Hindi po napupunta sa
kaliwa/kanan/gitna o sa likod?
● Duration: Gaano po katagal nyo nararamdaman ung pagsakit? Mga ilang minuto po sya masakit? After po
nitong _ mins nawawala na or may mild pain pa rin po?
● Character: Yung sakit ho ba parang pinipilipit po ba o humihilab o nandyan lang?
● Severity: Kung irate nyo po yung pagsakit into 1-10, 1 bilang pinakamababa at 10 bilang pinakamataas? Mga
gaano po ito kalala?
● Temporal: may specific na oras po ba kung kelan nyo nararamdaman? Pagkakain? gabi o umaga? (if 45+
nagreregla pa ho ba kayo ngayon?) Kailan nga ho ang huling regla nyo? Hindi sya sumasakit pag nireregla?
Mga ilang araw po pagkatapos ng regla nyo nararamdaman yung sakit?
● Aggravating: May napansin po ba kayong nagpapalala ng inyong nararamdaman? Pag umuubo, pag
nagbubuhat?
● Relieving: Ano pong ginagawa nyo para mawala po ung sakit? May iniinom po ba kayo na gamot? Basta ho ba
nawawala yung sakit? Hindi ho kailangan madumi kayo o mautot or maihi para mawala yung sakit?
● Associated: May iba pa po ba kayong nararamdaman paglalagnat pagsusuka pagkahilo panghihina mabilis
mapagod? May abnormal po bang discharge na nakikita sa panty? wala naman po kayong nakakapang parang
bukol sa may tyan nyo?
● Nakapagkonsulta ka na ba dati nung nakaramdam ka nang ganyan? Ano ho sabi ng doctor? May nireseta ba
sayong mga gamot?
VAGINAL DISCHARGE:
● Onset: Kailan nyo ho ito unang napansin?
● Character: Pano nyo po idedescribe yung discharge? Malagkit ho ba o parang matubig tubig lang? Sa kulay
po, maputi po ba, maberde, mabbrown or parang may dugo dugo? Sa amoy ho? Parang mabaho po ba?
Malansa o wala namang amoy? Gano ho karami tong discharge na to? Nagpapanty liner po ba kayo? Ngayong
may discharge po kayo nakakailang palit po kayo ng pantyliner?
● Duration: Ilang buwan na po kayong may discharge na ganyan? Napapansin nyo po sya araw araw? First time
nyo lang po ba ito maexperience? Dati ho walang mga ganyang discharge?
● Aggravating: May ginagawa po ba kayo bago nyo mapansin tong discharge? Kagaya ng katatapos nyo lang
makipagtalik, o pagkatapos ng regla? Kung irerelate po sa regla ilang days po after ng regla nyo sya
napapansin?
● Relieving: tuwing kelan nyo pa sya napapansing nawawala?
● Associated: Hindi naman po kayo nilalagnat? Walang pangangati sa pwerta? Walang masakit sa bandang
pwerta o sa tyan? Hindi masakit ang pag-ihi? Hindi ho sya sumasakit pag nagtatalik? Wala kayong
napapansing tumutubo sa pwerta?
○ GO TO OTHER SYMPTOMS:
○ Abdominal pain: CHECK HPI FOR ABDOMINAL PAIN
○ Fever: Kailan ka naglagnat? Ano pinakamtaas na temp ang nakuha mo? May ininom ka bang gamot
para sa lagnat? Wala bang ubo at sipong kasama yan?
○ Dyspareunia: Tuwing kelan sumasakit? Sa pagpasok ba ng ari? Sa buong oras na nagtatalik o
pagkatapos na ng pagtatalik?
○ Dysuria: kelan nagsimula sumakit ang pag ihi mo? tuwing kelan sya sumasakit? Sa unang pag ihi, sa
gitna ba o pagkatapos? Kamusta ang pag ihi mo ngayon? Ano ang ginagawa mo para mawala ang
sakit? Narerelieve ba?
● Yung asawa mo wala namang napapansing discharge? Hindi sya nagcocomplain na masakit ang pag-ihi nya?
ABNORMAL UTERINE BLEED

● Onset: Kailan pa po nagsimula? Tuloy tuloy lang po ba ang pagdudugo? Hindi po sya tumigil?
● Character: Pano po yung pagdudugo? Spotting lang po ba or marami? Nakakailang pads po kayo per day?
Regular or night pads? Napupuno po ba?
● Aggravating: May napapansin ka bang mga gawain na nagpapalala ng pagdugo?
● Relieving: May ginagawa ka ba para mawala yun or mabawasan?
● Associated:
○ Di naman nahihilo? Pamumutla? Headache?
○ Dysmenorrhea: Nakakaranas po ba kayo ng pagsakit ng puson dahil dito? Tuwing kelan?
○ Infertility: Nagtatry ho ba kayo ni mister na makabuo ng anak? Gano katagal na po kayong nagtatry?
○ epistaxis, bruising, gum bleeding, postpartum hemorrhage and surgical bleeding (pagdugo ng ilong at
gilagid, labis na pagdugo pagkatapos manganak?, nasalinan ba kayo ng dugo (if may past surgery)
○ Hypothyroidism s/sx: Weight gain, cold intolerance, constipation, bradycardia (Sumikip ba yung damit,
madali lamigin, hirap sa pagtae, sa PE na yung brady)
● Temporal
● MENSTRUAL HISTORY: Kailan po ang unang araw ng huling regla nyo? Regular po ba kayo nireregla? Ilang
araw po ba ang usual na tinatagal? Nakakailang napkin ka per day?
○ M - Ilang taon po kayo nung una kayong niregla?
○ I - Regular po ba kayo nagreregla? Kunyari ho July 10 niregla kayo, kailan po ninyo ineexpect ang
susunod nyong regla?
■ If irregular: mga gaano po katagal na hindi kayo nireregla? Mga ilang bwan po kayong hindi
dinadatnan?
○ D - Ilang araw po ito nagtatagal? Sa _ na araw na to, kasama na po ba yung mga pahabol na regla?
○ A - Ilang pads po ang nagagamit nyo kada araw ng regla? Ano po ang gamit nyo regular pads o night
pads? Fully soaked pads po ba to? May buobuo po bang dugo kayong napapansin (blood clots)?
○ S - May nararamdaman po ba kayong sintomas tuwing dinudugo? Sakit sa puson, pagkahilo,
pagsusuka?
AMENORRHEA
● Onset: Kailan niyo po napansin na tumigil na yung pagmemens nyo? (differentiate primary: no mens ever til 15
y/o from secondary: no mens 6-12 months)
● History of UTI: Madalas po ba kayong nagpapacheck up dahil sa masakit na pag ihi? Ano po yung payo ng
doctor sa inyo? (ask if primary ameno)
● Associated s/s:
○ Weight loss: (Napansin niyo po ba kung namayat kayo? Alam niyo po ba ang usual body weight nyo?
Napapansin niyo po ba kung nagsiluwagan yung mga damit niyo?)
○ Tumor mass effects: headache, blurring of vision (prolactinoma)
● Ask for Danger signs of pregnancy

○ Blurring of vision, headache, convulsions, edema of hands and feet (preeclampsia)
○ Fever, dysuria (UTI)
○ Abdominal pain/hypogastric pain-> preterm labor and abortion
○ Persistent nausea and vomiting-> GTD and multifetal pregnancy
○ Watery/bloody discharge (threatened abortion)
○ No danger signs of Pregnancy
REVIEW OF SYSTEMS (Summary)

Napansin nyo po bang biglang bumaba ang timbang ninyo? May pagbabago po ba sa inyong pagkain? Pagtulog?
Mabilis ba kayong mapagod? Wala naman po ubo, sipon, hirap sa paghinga? May pagbabago po ba sa pagdudumi?
Sa pagihi? Napansin nyo po ba kung madali kayong magkapasa o namumutla po ba kayo? Di naman po palaging
uhaw o gutom? Hindi naman init na init o nanlalamig?
If you want specific use this, but if not then skip

1. General or Napansin mo bang pagbabago sa timbang (for sure meron kasi buntis),
constitutional panghihina? pagkawalang gana sa pagkain? pagbabago sa pagtulog?
symptoms
2. Skin/ Hair/ Nails may napapansin po ba kayong nakakaiba or nararamdaman sa kahit

anong parte ng inyong balat? Nakakaranas ka ba ng pangangati? May
mga rashes ba?
3. Head and Neck EYES: Walang naman problema sa paningin?

Walang panlalabo ng paningin? pagkaduling?
MOUTH: Pagdudugo sa gilagid?, pagkawala ng panlasa?
NECK: May napansin po ba kayong bukol sa may leeg?
4. Breasts Nagseself breast exam po ba kayo? If yes, May nakakapa po kayong

bukol? Discharge? May lumalabas na gatas?
5. Pulmonary - ask for Wala namang ubo? Sipon? hindi hirap sa paghinga? Pananakit ng
COVID dibdib?
6. Cardiac May napansin po ba kayong pagbilis sa pagtibok ng puso? Madaling

mahingal?
7. Abdominal Wala naman pong pananakit ng tyan? Wala naman po pagbabago sa

pagdudumi? Hindi po ba kayo hirap dumumi ngayon? Araw araw naman
po? Walang dugong napapansin? Di naman po ito matubig? Diarrhea?
8. Genitourinary Napapansin nyo po bang kakaiba sa inyong pagihi tulad ng madalas na

pag-ihi? Bumabangon po madalas sa gabi para umuhi? Hirap sa pagihi?
May pakiramdam na di kumpleto ang pagihi?
9. Hematologic Walang abnormal na pagdudugo, pagpapasa, at pamumutla?
10. Endocrine - check for Hindi ka naman palaging uhaw? Gutom? Hindi laging init na init o lamig
GDM na lamig?
11. Musculoskeletal May nararamdaman po bang pananakit ng katawan?
12. Neurological Sumasakit po ba ang ulo ninyo o Nahihilo? (already asked sa HPI)
13. Psychiatric Pagkanerbyos? May napapansin ho ba kayong pagbabago ng inyong
mood? O may nararamdamang depression?
MENSTRUAL HISTORY
Tungkol naman po sa regla po ninyo noon
LMP - Kailan po ang unang araw ng huling regla nyo? Yung regla po bang to parang yung usual nyo o parang spotting
lang?
PMP - Bago po ung [month of LMP], kailan po ung huli nyo pang regla?
● M - Ilang taon po kayo nung una kayong niregla?
● I - Regular naman po ba ang regla nyo? Mga ilang araw po ang pagitan? Kunyari ho April 5 niregla kayo, kailan
po ninyo ineexpect ang susunod nyong regla?
○ If irregular: mga gaano po katagal na hindi kayo nireregla? Mga ilang bwan po kayong hindi
dinadatnan?
● D - Ilang araw po ito nagtatagal?
● A - Ilang pads po ang nagagamit nyo kada araw ng regla? Ano po ang gamit nyo regular pads o night pads?
Napupuno po ba to? May buobuo po bang dugo kayong napapansin (blood clots)?
● S - May nararamdaman po ba kayong sintomas tuwing nagreregla? Tulad ng sakit sa puson, pagkahilo,
pagsusuka? Tuwing anong araw po ito ng regla nangyayari (may iniinom po ba kayo na gamot? Nawawala po
ba?)
OB HISTORY
● GP (TPAL) nasabi nyo po kanina may anak po kayo
● G: Ilan na po ang anak ninyo? Nakunan na ho ba kayo? Pagbubuntis sa labas ng matres? Kasama na po ba to
dun sa ___? So bale ___ po lahat? Wala po yung tulad ng kyawa? Yung ___ po na anak ninyo kamusta
naman? kasama nyo po ba lahat sa bahay? Ask for history of congenital anomalies na din if high risk
● Anong taon po yung una ninyong pagbubuntis? Babae po ba o lalake
● Yung ikalawa po?
● Lahat po ba to ay nasa kabwanan (term or preterm)? Naalala nyo po ba kung ano timbang nila? Lahat po ba to
normal delivery or may Cesarean po kayo? (bakit po kayo naCS?) San po kayo nanganak? (Ano hong ospital?)
Sa lahat po ng pagbubuntis, may naging komplikasyon po ba nung (High blood, diabetes)? Ang baby po okay
naman walang naging komplikasyon?
○ C/S common reasons: Pre-eclampsia, placenta previa
○ Place: If lying in - episiotomy is not done
○ Complications e.g. GDM, pre-eclampsia, UTI, PPH, postpartum fever
● Nung nakunan po kayo, ano pong year ito? Naraspa ho ba kayo? (Lumabas na lang po lahat?) Ilang buwan po
ito?
● Lahat po ng pagbubuntis nyo, iisa lang po ba ang tatay?
SEXUAL HISTORY
Pasensya na ma’am, medyo sensitibo at personal lang po ang mga susunod ko na itatanong pero kailangan po kasi
itanong dahil kasama po ito sa history taking.
● Coitarche: ilang taon po kayo nung unang beses kayo nagkaroon ng sexual contact/ unang pagtatalik
● # sexual partners:
if married, si Mr. lang po ba ang sexual partner ninyo? If not, ilan po ang sexual partner niyo?
If single: Ngayon po ba may sexual partner po kayo? Ilan po ang sexual partner ninyo?
● Occupation of sexual partners: Ano po ang trabaho ng partner nyo ngayon. Elicit promiscuity of patient (risk
factor for STDs like HIV)
● Note: If high risk, can also ask for history of STDs and treatment
● Regularity/Last contact: Ngayon po, sexually active kayo? Mga ilang beses po kayo nagcocontact sa isang
linggo? Kelan po ang huling contact nyo? Gaano katagal na po kayo nakikipagtalik ng inyong partner? (how
long the relationship lasted)
● Symptoms: May napapansin po ba kayong sintomas tuwing nakikipagtalik kayo? Tulad ng pagdudugo
pagkatapos (post coital bleeding), o masakit po ba tuwing nakikipagtalik (dyspareunia) - if yes, ask if insertional
or pag nilalabas, o kaya bigla po kayong nagkakadischarge na may amoy o malansa?
● Family Planning Methods: Tanong ko lang po if gumagamit kayo ng family planning method? Tulad ng
contraceptives pills o condom? Gaano katagal nang ginagamit? (Kahit dati po hindi kayo gumagamit? natural
method po kayo? Ano po ginagamit nyo? (withdrawal, calendar, abstinence?)
CURRENT HEALTH STATUS
● Naninigarilyo? Ilang sticks or packs per day?
● Umiinom po ba ng alak? Tuwing kelan po?
● Gumagamit po ba ng mga pinagbabawal na droga?
● Diet & Exercise
PAST MEDICAL HISTORY

● Comorbidities: May ibang sakit po ba kayo tulad ng hypertension, diabetes, asthma, TB, sakit sa thyroid,
Stroke, Cancer, Gout, nadiagnose ng PCOS?
○ History of placenta previa
○ Gyne tumors (cancer sa matres, obario)
● Past hospitalizations/surgeries: Naospital na po ba dati? Naoperahan na po ba dati?
○ If yes, ask year, reason for operation, any complication?
● Injuries/ Accidents: Naaksidente na po ba dati?
● Blood transfusion: Nasalinan na po ba ng dugo?
● Immunizations: Nabakunahan na po ba laban sa cervical cancer o HPV vaccine? Nagkaroon na po ba ng flu
vaccine? Tetanus? COVID-19 vaccine?
● Current Medications/Supplements: May mga gamot po ba kayong iniinom ngayon? Para saan po ito?
Generic name, brand, dose? Self-prescribed/ doctor prescribed? [If HTN or DM, ask if controlled BP or blood
sugar level]
● Allergies: Meron po bang allergies sa pagkain o gamot? Sa pain relievers po wala?
● ASK FOR PREVIOUS PRE-NATAL CHECK UPS?
● Nakakapagblood chem po ba ayo taon taon? Nakakapagpacheck po ng dugo?
● Ask for any ancillaries if available like TVS or labs
● Important to ask for Ultrasound results esp early ultrasound para make sure yung AOG
FAMILY HISTORY
● Sa pamilya naman po ninyo, Meron po bang lahi ng dyabetis, high blood, Thyroid Disorders (goiter), cancer,
sakit sa dugo, asthma, TB? Heart attack o sakit sa puso? Na-stroke? Wala naman po sa pamilya ang may
problema din sa pagreregla?
PERSONAL AND SOCIAL HISTORY

● Kamusta naman po ang inyong trabaho?
● Relation sa mga kapamilya/kaibigan?
Dito po nagtatapos ang ating history taking. May mga katanungan po ba? Salamat po
OB ESGD
Date: August 27, 2021 (Friday)
Facilitator: TCL
SCRIPT
INTRO AND GEN DATA

● Good morning, ako po si, clinical clerk ____ . Narito po kami para kunin ang history ninyo.
● Ano po ang pangalan ninyo?
● Married or single? Ilang taon na po kayo kasal? May anak na po ba?
● Nationality? Relihiyon?
CC:
● Ano po ang dahilan ng pagkonsulta nyo ngayon?
HPI:
MISSED MENSES:
● Kelan pa po ito nagsimula?
● Kelan po ang unang araw ng huling regla mo? Ito ba yung usual na regla mo, or napansin mong mas kaunti?
● Regular naman po?
○ Nahihilo? Nagsusuka? Parang nasususka? Sinisikmura? Ihi ng ihi? Medyo sumasakit po ba yung dibdib nyo?
● Nasubukan mo na bang magpregnancy test?
PRENATAL CHECK UP
● Signs of labor:
○ May nararamdaman na po bang contractions (o paninigas ng tiyan)? Gaano po katagal yung contraction and
gaano katagal yung pagitan ng dalawang contractions?
○ Tuloy tuloy na pagsusuka?
○ Walang panlalabo ng mata?
○ Walang kahit anong lumalabas sa puwerta? Discharge na matubig o may dugo?
If DM mommy:
ABDOMINAL PAIN
● Duration: Gaano po katagal nyo nararamdaman ung pagsakit? Mga ilang minuto po sya masakit? After po nitong _ mins
nawawala na or may mild pain pa rin po?
● Severity: Kung irate nyo po yung pagsakit into 1-10, 1 bilang pinakamababa at 10 bilang pinakamataas? Mga gaano po ito
kalala?
● Temporal: may specific na oras po ba kung kelan nyo nararamdaman? Pagkakain? gabi o umaga? (if 45+ nagreregla pa
ho ba kayo ngayon?) Kailan nga ho ang huling regla nyo? Hindi sya sumasakit pag nireregla? Mga ilang araw po
pagkatapos ng regla nyo nararamdaman yung sakit?
● Aggravating: May napansin po ba kayong nagpapalala ng inyong nararamdaman? Pag umuubo, pag nagbubuhat?
● Relieving: Ano pong ginagawa nyo para mawala po ung sakit? May iniinom po ba kayo na gamot? Basta ho ba nawawala
yung sakit? Hindi ho kailangan madumi kayo o mautot or maihi para mawala yung sakit?
● Associated: May iba pa po ba kayong nararamdaman paglalagnat pagsusuka pagkahilo panghihina mabilis mapagod?
May pagdudugo po or lumalabas sa pwerta? wala naman po kayong nakakapang parang bukol sa may tyan nyo?
● Nakapagkonsulta ka na ba dati nung nakaramdam ka nang ganyan? Ano ho sabi ng doctor? May nireseta ba sayong mga
gamot?
VAGINAL DISCHARGE:
● Character: Pano nyo po idedescribe yung discharge? Malagkit ho ba o parang matubig tubig lang? Ano po ang kulay? Sa
kulay po, maputi po ba, maberde, mabbrown or parang may dugo dugo? Sa amoy ho? Parang mabaho po ba? Malansa o
wala namang amoy? Gano ho karami tong discharge na to? Nagpapanty liner po ba kayo? Ngayong may discharge po
kayo nakakailang palit po kayo ng pantyliner?
● Duration: Ilang buwan na po kayong may discharge na ganyan? Napapansin nyo po sya araw araw? First time nyo lang po
ba ito maexperience? Dati ho walang mga ganyang discharge?
● Aggravating: May ginagawa po ba kayo bago nyo mapansin tong discharge? Kagaya ng katatapos nyo lang makipagtalik,
o pagkatapos ng regla? Kung irerelate po sa regla ilang days po after ng regla nyo sya napapansin?
● Associated: Hindi naman po kayo nilalagnat? Walang pangangati sa pwerta? Walang masakit sa bandang pwerta o sa
tyan? Hindi masakit ang pag-ihi? Hindi ho sya sumasakit pag nagtatalik? Wala kayong napapansing tumutubo sa pwerta?
○ Fever: Kailan ka naglagnat? Ano pinakamtaas na temp ang nakuha mo? May ininom ka bang gamot para sa
lagnat? Wala bang ubo at sipong kasama yan?
○ Dyspareunia: Tuwing kelan sumasakit? Sa pagpasok ba ng ari? Sa buong oras na nagtatalik o pagkatapos na ng
pagtatalik?
○ Dysuria: kelan nagsimula sumakit ang pag ihi mo? tuwing kelan sya sumasakit? Sa unang pag ihi, sa gitna ba o
pagkatapos? Kamusta ang pag ihi mo ngayon? Ano ang ginagawa mo para mawala ang sakit? Narerelieve ba?
Ask for Danger signs of pregnancy!


Napansin nyo po bang biglang bumaba ang timbang ninyo? May pagbabago po ba sa inyong pagkain? Pagtulog? Mabilis ba kayong
mapagod? Wala naman po ubo, sipon, hirap sa paghinga? May pagbabago po ba sa pagdudumi? Sa pagihi?(frequency, urgency,
dysuria, last output) Di naman po palaging uhaw o gutom? Hindi naman init na init o nanlalamig?
MENSTRUAL HISTORY
LMP - Kailan po ang unang araw ng huling regla nyo? Yung regla po bang to parang yung usual nyo o parang spotting lang?
● I - Regular naman po ba ang regla nyo? Mga ilang araw po ang pagitan?
○ If irregular: mga gaano po katagal na hindi kayo nireregla? Mga ilang bwan po kayong hindi dinadatnan?
● A - Ilang pads po ang nagagamit nyo kada araw ng regla? Ano po ang gamit nyo regular pads o night pads? Napupuno po
ba to? May buobuo po bang dugo kayong napapansin (blood clots)?
● S - May nararamdaman po ba kayong sintomas tuwing nagreregla? Tulad ng sakit sa puson, pagkahilo, pagsusuka?
Tuwing anong araw po ito ng regla nangyayari (may iniinom po ba kayo na gamot? Nawawala po ba?)
OB HISTORY
● G: Ilan na po ang anak ninyo? Nakunan na ho ba kayo? Pagbubuntis sa labas ng matres? Kasama na po ba to dun sa
___? So bale ___ po lahat? Wala po yung tulad ng kyawa? Yung ___ po na anak ninyo kamusta naman? kasama nyo po
ba lahat sa bahay? Ask for history of congenital anomalies na din if high risk
● Lahat po ba to ay nasa kabwanan (term or preterm)? Naalala nyo po ba kung ano timbang nila? Lahat po ba to normal
delivery or may Cesarean po kayo? (bakit po kayo naCS?) San po kayo nanganak? (Ano hong ospital?) Sa lahat po ng
pagbubuntis, may naging komplikasyon po ba nung (High blood, diabetes)? Ang baby po okay naman walang naging
komplikasyon?
● Nung nakunan po kayo, ano pong year ito? Naraspa ho ba kayo? (Lumabas na lang po lahat?) Ilang buwan po ito?
SEXUAL HISTORY SKIP if not needed!

Pasensya na ma’am, medyo sensitibo at personal lang po ang mga susunod ko na itatanong pero kailangan po kasi itanong dahil
kasama po ito sa history taking.
● Occupation of sexual partners: Ano po ang trabaho ng partner nyo ngayon. Elicit promiscuity of patient (risk factor for
STDs like HIV)
● Regularity/Last contact: Ngayon po, sexually active kayo? Mga ilang beses po kayo nagcocontact sa isang linggo? Kelan
po ang huling contact nyo? Gaano katagal na po kayo nakikipagtalik ng inyong partner? (how long the relationship lasted)
● Symptoms: May napapansin po ba kayong sintomas tuwing nakikipagtalik kayo? Tulad ng pagdudugo pagkatapos (post
coital bleeding), o masakit po ba tuwing nakikipagtalik (dyspareunia) - if yes, ask if insertional or pag nilalabas, o kaya bigla
po kayong nagkakadischarge na may amoy o malansa?
● Family Planning Methods: Tanong ko lang po if gumagamit kayo ng family planning method? Tulad ng contraceptives pills
o condom? Gaano katagal nang ginagamit? (Kahit dati po hindi kayo gumagamit? natural method po kayo? Ano po
ginagamit nyo? (withdrawal, calendar, abstinence?)

● Diet & Exercise

● Comorbidities: May ibang sakit po ba kayo tulad ng hypertension, diabetes, asthma, TB, sakit sa thyroid, Stroke, Cancer,
Gout
● Immunizations: Nabakunahan na po ba laban sa cervical cancer o HPV vaccine? Nagkaroon na po ba ng flu vaccine?
Tetanus? COVID-19 vaccine?
● Current Medications/Supplements: May mga gamot po ba kayong iniinom ngayon? Para saan po ito? Generic name,
brand, dose? Self-prescribed/ doctor prescribed? [If HTN or DM, ask if controlled BP or blood sugar level]
ASK FOR PREVIOUS PRE-NATAL CHECK UPS?

● Ask for any ancillaries if available like TVS, CBC, UA, FBS, (or 75gOGTT on next visit)
● Ask for Ultrasound results esp early ultrasound para make sure yung AOG, viability, location
FAMILY HISTORY
● Sa pamilya naman po ninyo, Meron po bang lahi ng diabetes, hypertension, asthma, Cancer, sakit sa dugo, Thyroid
Disorders (goiter), TB? Wala naman po sa pamilya ang may problema din sa pagreregla?

!! GO straight to Focused PE table !!

Click here to skip → FOCUSED PHYSICAL EXAMINATION
-------------------- INPUT DATA HERE --------------------
GENERAL DATA
Name AV Religion Gravida
Age 28 Occupation Address Para
Birthday Nationality Filipino Educational TPAL

attainment
Birthplace Civil Status Contact no.
CHIEF COMPLAINT Abdominal pain
HISTORY OF PRESENT ILLNESS
Onset Last night

Location Whole abdomen
Duration Continuous
Character (+) minimal Bloody vaginal discharge
Associated Symptoms
No meds
Aggravating Factors
Alleviating factors
Time LMP Nov 15 (40-41 wks AOG)
Severity EDC: Aug 22, 2021
Medications
Prenatal check ups - unremarkable
REVIEW OF SYSTEMS
General or constitutional symptoms
Skin/ Hair/ Nails
Head and Neck
Breasts
Pulmonary
Cardiac
Abdominal
Genitourinary
Hematologic
Endocrine
Musculoskeletal
Neurological
Psychiatric
MENSTRUAL HISTORY
LMP LMP Nov 15 PMP

(40-41 wks AOG)
Menarche y/o Interval days
Duration days Amount

Soaked
Blood clots
Symptoms +
Medications
OBSTETRIC HISTORY
GP(TPAL) Gravidity: G1
Parity: P0
G1 (Year):
● BB boy/girl?
● AOG
● BW
● NSD or C/S
○ Indication:
● Where:
● Complications:
G2 (Year):
● BB boy/girl?
● AOG
● BW
● NSD or C/S
○ Indication:
● Where:
● Complications:
SEXUAL HISTORY
Coitarche yrs old # of partners Total:

Occupation:
Regularity:
Last contact:
Family planning Symptoms Post-coital bleeding:

methods Dyspareunia:
Smoking
Alcohol
Illicit drugs
Past surgeries,
hospitalizations, transfusion
Injuries/ Accidents
Obstetric & gynecological Pre-natal check-ups - normal

procedures
Allergies
Immunization HPV:
DPT:
FLU:
COVID:
Comorbidities
Medications
FAMILY HISTORY
DM, HPN, asthma, thyroid none

diseases, PCOS, cancer,
blood dyscrasias
FOCUSED PHYSICAL EXAMINATION
General Survey Ask patient to void prior to PE

Conscious, coherent, ambulatory, not in respiratory distress
Vital Signs BP: 120/80

HR: 82
RR: 21
Temp: afebrile
O2 sat:
Anthropometrics Weight
- Pre-pregnancy unrecalled
- Current (if avail) 135 - 26.4 BMI
Height 5’
BMI and Classification Current/preg BMI = 26.4
HEENT
Head:
Eyes:
● Pink palpebral conjunctiva
● Anicteric sclera
Ears:
Nose:
Mouth:
Neck:
● No anterior neck mass
● Thyroid midline and moves with deglutition, Thyroid not enlarged, (-) bruit
● No palpable cervical lymphadenopathy
SKIN/ SUBCUTANEOUS
● No lesions, No Active dermatoses
PULMONARY
Inspection Symmetrical
No deformities, No use of accessory muscles
Palpation Symmetrical chest expansion, normal tactile fremitus
Percussion Resonant
Auscultation Clear Breath sounds, no wheezing or rhonchi
CARDIOVASCULAR
● Adynamic Precordium
● Apex beat at 5th ICS MCL
● (-) Heaves, lifts, thrills
● No murmurs
BREAST EXAM
Inspection ● Skin changes e.g. skin retractions and dimpling, discoloration

● Nipple changes e.g. nipple retractions/ visible lesions
Additionals:
- Asymmetry
- Before assuming asymmetry, always ask if it is always have been asymmetrical
- The dominant side usually appear larger than the other side
- Swelling
Palpation ● No masses
○ Size, location, consistency, mobility, tenderness, borders
● No tenderness
● No lymphadenopathies - size, consistency, fixation
○ Axillary LN
○ Regional LN - Supraclavicular, Infra, cervical
● No Discharge
ABDOMINAL EXAM
Ideally, drain the bladder!
Inspection ● Contour: Globular

● With Scars? Ex. C/S scars/Appendectomy scar (surgical scars) - None
● Fundic height (done in 20-34 wks): 34 cm
Auscultation ● Normoactive/ Hyperactive/Hypoactive bowel sounds, (-) bruit

● Fetal heart tones (as early as 16 wks and surely at 22 wks):140 bpm
Palpation ● Leopold’s maneuvers

○ LM1 - fundal grip
○ LM2 - Umbilical grip fetal back R/L
○ LM3 - Pawlick’s grip - presentation
○ LM4 - pelvic grip - side of cephalic prominence and if engaged or not
● Uterine Contractions: every 2-3mins ,mod-strong, 40-50secs
● Fetal movements:
● Direct and rebound tenderness; if Appendicitis - Rovsings, Psoas, Obturator sign
● Masses
○ If present, ask for size, consistency, mobility
● Guarding, board like rigidity (signs of peritonitis)
● Hepatomegaly (NV: Liver span 12 cm R MCL)
Percussion Do not percuss pregnant patients
GENITOURINARY
CVA Tenderness
EXTREMITIES
Pulses, Deformities ● Pulses full and equal = 2+, DTR

● Deformities?
PELVIC EXAM
Inspection and ● External genitalia

palpation ○ Inspect the Vulva
(External ■ No Scars
Genitalia) ■ No Erythema
■ No Bleeding
■ No Discharge
○ No gross lesions or masses (rash/ vesicles/ulcerations), episiotomy scar
○ No masses nor tenderness on palpation of perivaginal area
SPECULUM EXAM
Vagina Erythema, lesions

Vaginal discharge (if present): color, consistency, amount
Cervix Cervix is violaceous, everted (anterior or posterior), violaceous, smooth with minimal mucoid
whitish non-foul discharge, no lesions
Others: Cervical ectropion, Ulcers, Masses/ Polyp
INTERNAL EXAM
Cervix ● Cervix - 7-8 cm, 80-90% effaced, LOA, Station 0

● No Cervical motion tenderness
If late part of pregnancy:
● Check presenting part and station
● Estimate pelvic capacity and configuration
● Cervical consistency
● Effacement and Dilatation!
○ D-ilatation
○ Effacement
○ P-osition
○ A-mniotic membranes
○ P-resentation
○ S-tation
Uterus Bimanual exam: Uterus enlarged by how many months, anteverted, non-tender
Adnexa No adnexal mass nor tenderness (cannot be assessed by 12-16 weeks)
RECTAL EXAM (If warranted ex. Endometriosis or presence of mass)
● Tight sphincteric tone

● Smooth rectal mucosa
● No blood on tactating finger
Inspection
• Skin Excoriation, Rashes, Hemorrhoids, Anal Fissure, Bleeding, Fistulae, Abscesses
Palpation
● Cervix
● Size of the Uterus
● Adnexal area
○ Ideally, there is nothing to feel or palpate in the adnexal area
○ Any mass that can be palpated in the area is considered a suspicious abnormality
● Shift to the right side and left side. Assess the anal sphincter tone (Ask the patient to squeeze the finger)
● In rectal exam (or RVE), you can palpate for tender nodularities in the uterosacral ligaments (endometriosis)
Withdraw and inspect finger and assess for Blood, Stool, Mucus
RECTOVAGINAL EXAM
Palpation Palpate the tissue in between the rectum and the vagina (rectouterine pouch of douglas)
- Nodularity
- Tenderness
- Masses
For the rectal finger, palpate the integrity of the rectal mucosa and presence of mass.
- Rectal Mass
SALIENT FEATURES
We have a case of a 28 y/o primigravid, 40-41 wks AOG,,,,

came in due to chief complaint of: Abdominal Pain
History started:
Yesterday the patient experienced abdominal pain (severity was not noted)
ROS was unremarkable
LMP: Nov 15
PMP:
M-
I-
D- days
A - pads/day regular pads moderately soaked; no clots
S- No dysmenorrhea
OB Hx again px is G0 P ( )
Her ____ pregnancies were all carried and delivered to term with no complications
____ pregnancy was delivered via cesarean due to ____ no complications
PMH - unremarkable
FH - unremarkable
Sexual Hx - coitarche at age ; with total sexual partners
Objective Findings:
FH 34
FHT 140 bpm
Uterine contractions: every 2-3 mins mod to strong for 40-50 sec
7-8 cm dilatation
80-90% effacement
LOA
Station 0
● Normal pelvic exam - external, spec, IE
○ External genitalia:
○ Speculum exam ss unremarkable
○ Internal examination was unremarkable
CLINICAL IMPRESSION
G1P0 pregnancy uterine, 40-41 wks AOG by LMP, (cephalic) LOA, in labor
Signs and Abdominal pain

Symptoms Uterine contractions: every 2-3 mins mod to strong for 40-50 sec
7-8 cm dilatation
80-90% effacement
Physical
examination
Diagnostic/
ancillary * If need surgery, dont forget to request for cbc, blood chem, pt/ptt etc. and COVID-19
rt-pcr swab test!
Request for:
● CBC
● Blood typing
● RT PCR swab
● Possibly also: HBsAg, RPR
Management Management Goals:
Admission to labor room

Hook to EFM LABOR ADMISSION TEST
● Monitor FHR every
● Check:
○ Baseline FHR
○ Accelerations, Decelerations
Diet NPO
Maintain bed rest
Monitor vitals signs and Fetal heart tone every 30 mins
Establish IV line, ) IV (D5W: 20-30 gtts/min) - Iv D5Lr 1 liter for 8 hours
Monitor progress of labor

Uterine contractions: interval,duration,intensity
Epidural anesthesia (ropivacaine)
DIFFERENTIAL DIAGNOSIS
Differentials
Signs and
Symptoms
Physical
examination
Reason for R/O
Diagnostic/
ancillary
Management
EXTRA NOTES:
DIAGNOSTICS/ ANCILLARIES (ROUTINE IN BOLD, MANAGEMENT)
Ultrasound To determine the fetal viability and confirm location if intrauterine pregnancy (r/o
ectopic pregnancy which is extrauterine, especially if patient is irregular
menstruation or irregular menses
TVS: <12 weeks,
*if confirm mo na napregnant sya, no need for immediate ultrasound
Transabdominal UTZ: if>12 weeks, fetal biometry din ata tawag sa transabdominal
UTZ. measure the crown rump length, AOG and fetal aging
BPS done starting 28 weeks to assess fetal well being

(amniotic fluid index, fetal tone, fetal movement, fetal breathing and fetal heart
rate)
FBS +/- Lipid profile If high risk 75 oGTT agad: fbs 92, (1)180, (2) 153
If non high risk FBS muna if <92 normal then go back ng 24-28 weeks then if
normal go back ng 32 weeks
If 92-126 GDM
If >126 overt DM
*note if GDM =38 weeks deliver-41 weeks

Tx:
1. diabetic diet (Normal:30-35 kcal/kg, obese 24 kcal/kg/day)
Caloric composition: carbs 55%,protein20%, fats 25%
2. Refer to Dietary service
3. 1 pt CBG monitoring
4. Refer to endo and fetal surveillance
5. 2nd trimester: do sonographic imaging for congenital anomalies
6. 3rd trimester fetal surveillance
7. You can give insulin pero aralin ko nalang
Urinalysis UTI and renal function

Culture for asymptomatic bacteriuria
CBC + PLT 1st trimester=11

2nd=10.5
3rd=11
To know the hematologic status and physiologic anemia

For leukocytosis if may infection
ABO XT BT Determine ABO, RH status for hemolytic transfusion
Serology Hbsag:
Determine Hep B status, for possible intervention
* Use double glove delivery
* Give the neonate Ig & HepB vaccine immediately after
delivery if reactive!
Ideally done on 1st trimester, repeated on the 3rd
* Can be done in the 3rd trimester for cost-effectiveness * Greatest transmission is during
the 3rd trimester
Syphilis
Done near term (3rd trimester)
Detect previous or current infection of syphilis
Non-treponemal (nonspecific) screening tests
● * VDRL (Venereal Disease Research Laboratory)
● * RPR (Rapid Plasma Reagin)
§ If positive, do treponemal (specific) confirmatory tests
● * FTA-ABS (Fluorescent Treponemal Antibody Absorption)
● * TP-MHA (Treponema Pallidum Microhemagglutination Assay)
HIV
Pap smear This is not usually done except if s/s of cervical cancer or foul smelling vaginal
discharge or post coital bleeding
For gyne
KOH smear
Coagulation studies
Iron studies
Thyroid function tests TSH, FT4, FT3
Extra Notes Prenatal work ups: (Initial visit)

● CBC with platelet count
● Urinalysis
● Blood typing
● Urine culture - if may signs of bacteriuria (since gold standard)
● FBS - always request for this since philippines
● HBsAg (sa 3rd trimester na)
● For STDs
○ VDRL/ RPR
○ HIV Elisa
● Pap smear
1ST TRIMESTER
● Request an early ultrasound for location of pregnancy, proper AOG, fetal
viability
Congenital anomaly scan if high risk - 15-20 wks for neural tube defects
AT 24-28 wks AOG

● 75g OGTT
● Biometry + BPS
Note: Always request for repeat CBC to check if may anemia lalo na if nearing
term
MANAGEMENT
1st Trimester Prenatal Vitamins

● Multivitamin 1 tab per day (vitamin D and zinc)
● Folic acid 0.4 to 0.8 mg (400 mcg) per day one month before conception to first
trimester (If with hx of NTD give 4mg/day instead)
● Drink 1-2 glass of milk per day OR Calcium 100mg per day (if no nausea and
vomiting)
Additional:
● Caloric intake should be 100-300 kcal per day
● Add protein to diet (egg)
2nd Trimester Prenatal Vitamins

● Multivitamins
● Iron (Ferrous sulfate 30 mg/day)
○ 27 mg elemental iron/day 30 mins premeal
○ Only give after 1st trimester d/t GI irritation
Prevention ● No alcohol, smoking, illicit drug use and caffeine <3 cups of 300mg/day
(Education) ● Advise vaccinations - Tdap 27 and 36 wks AOG, Flu vaccine at any AOG
○ If no vaccines: Flu and DPT (3 dose starting 2nd trimester 1 month apart last
dose postpartum)
● Stress importance of taking supplements and coming in for regular check up
● Educate patient of 10 danger signs and consult immediately once experienced
● If placenta previa - bed rest; avoid strenuous activity, coitus
● Stop smoking, drinking
Complications ● Nausea and vomiting of pregnancy - small frequent feeding, antiemetics

and Other ● If pre-eclampsia - give aspirin 150mg at 12 wks AOG if high risk
diseases ● If with heartburn = PPI
● If asthma
○ Avoid triggers
○ Adherence to medications SABA etc
● If GDM
○ Diet and exercise - diabetic diet
○ Daily CBG monitoring
Follow up All OB cases require follow up:

● <28 wks - monthly
● 28-36 wks - every 2 weeks
● >36 wks - every week
Presumptive signs Probable Positive
● Nausea (Morning sickness) ● Abdominal enlargement ● FHT

● Vomiting (Hyperemesis gravidarum) ● Cervical changes - soft, ● Fetal movement
● Urinary symptoms - frequency, UTI violaceous perception by examiner
● Fatigue ● Braxton hicks contraction ● Ultrasound
● Quickening - perception of fetal ● Ballottement
movement 16-18 in primi; 18-20 in multi ● Preg test
● Breast tenderness/ engorgement
● Amenorrhea >10 days of expected mens
● Skin pigmentation - striae, linea nigra
TCL comments:
● Cannot make a diagnosis of arrest in 1 hr
TBM: Can wait 1hr to see if the station progressed and if this would dilate to 8-9cm
If still not, then consider failure in descent
● Determine cause of problem first; “amniotomy is not the answer to all” daw hahaha
○ Can do clinical pelvimetry
● After chief complaint should have asked LMP na agad
● NPO not practiced in this case, check updated guidelines (ERAS)
● IV fluid is not routine in parturient
General Data
ACT: Introduce yourself as part of the medical team, like “kasama po ako ng residente…” (to build rapport!)
Name: Danica Cruz Age: 20 Birthday: Address: Tandang Sora
Civil Status: Single (Live in partner) # Years married: Nationality: Filipino

1 child
Education: Occupation: Student Religion: Catholic
Chief Complaint: Sumasakit ang tiyan Comments/Suggestions
HPI
If Pregnant/suspicious of preg: LMP November 23 39-40 39-40 weeks AOG

● LMP (then compute AOG stat!)
● Had PT, how many times, result
● Presumptive symptoms O - Kaninang madaling araw
○ Morning sickness (6-18) L - Upper area pababa then sa likod
○ Idiosyncrasies of taste and D - 1 min duration, every 15-20 minutes Regular?
smell
○ Fatigue C - Parang pinipiga
○ Urinary frequency, nocturia (1st A - No watery discharge, (+) bloody discharge, no headache, no blurring of Make sure focused hx.
& 3rd trimester) vision, no dysuria, no fever, (+) fetal movement Skip na mga iba muna
○ Amenorrhea
○ Breast engorgement
R-
○ Skin changes T - On and off → uncomfortable for the past 2 hours
○ Increased temp (6) S - 8/10
○ Quickening (P-18-20; M-16-18)
● Probable signs
○ Abdominal enlargement (12) Covid 19 vaccine???
○ Braxton Hicks (28) PNCU: 5 times at Local health center Test???
Labs:
10 Danger Signs (for Prenatal Check up)
1. Headache
4. Fever and chill
5. Nondependent Edema (hands,
periorbital)
7. Hypogastric pain
8. Dysuria
9. Water vaginal discharge
Amenorrhea, Pain, Discharge and Bleeding

● Onset
● Location
● Duration
● Character ● Normal CBC
● Assoc/Aggrav ● U/A - pyuria (prescribed with something; resolved)
● Allev
● Rad
● Tempo/Timing Follow up 75g oGTT
● Severity Repeat urinalysis 35-36 weeks A0G
If prenatal/follow-up:
● Where
● When last ff
● How many
● Weight gain
● Assessment
● Labs & Results
● UTZ: CRL (12), AOG, location of
fetus, placenta
● If abnormal labs: Ask what was
advised, prescription, intervention
Ultrasound: compatible with AOG

Dry cough
O: 2 days ago
L
D
C
A
A
R
T-pa-minsan minsan
S
LMP: November 23, 2020 Comments/Suggestions

PMP:
AOG (if ever): 39-40 weeks AOG
EDD: Aug 30, 2021
MIDAS Menarche
If TERM preg: focused hx Interval Regular
does NOT include MIDAS Duration
na (“Your patient has big Amount
tummy, who cares of Symptoms
menarche”)
OB Hx G: 2 P: 1 TPAL: (1001)
If Pregnant AOG: 39-40 weeks EDC: August 30, 2021
2020 Live term Boy NSD None

Baby: (+) jaundice →
phototherapy → HDN
OB HX
Sexual hx Coitarche
# of Partners
Job of partners
Last sexual contact
Post Coital bleed
Dyspareunia
Family Planning
Past Medical hx Comorbids (HTN/DM/Thyroid) None

Medications Obimin (multivitamins) plus, Sangobion (iron supplement)
Surgeries Appendectomy
Transfusions
Hospitalizations
Immunizations
Prev Prenatal Check up
Personal & Social hx Smoking None

Alcohol Husband - chain smoker
Drugs
Diet
Exercise
Family hx DM Father - DM
HTN
Cancer
Asthma
Thyroid disease
Blood dyscrasia
Seizure
Heart disease
General (-) Weight Changes, (-) Changes in appetite, () Fever, () Chills, (-) Sleep Changes,
HEENT (-) Headache, (-) Blurring of Vision, () Exophthalmos
Cardio (-) Palpitations, (+) Easy fatigability
Pulmo (+) Dry Cough, (-) Colds, () Dyspnea, () Chest pain
GI (-) Vomiting, (-) Abdominal pain, () Dec Fetal Movement, () Constipation, () Diarrhea, () Hematochezia/
Melena
GU (see HPI) Dysuria, () Urinary frequency, () Nocturia, () Dribbling of urine
Hematologic () Pallor, () Easy bruising
Neurologic () Headache, () Seizure
Endocrine (-) Polydipsia, (-) Polyuria, (-) Polyphagia, () Heat intolerance, () Cold intolerance, () Irritability
MSK (-) Malaise, () Cramp
Extremities () Edema (nondependent), () Edema (dependent)
Prenatal Check up)
1. Headache
4. Fever and chill
5. Nondependent
Edema (hands,
periorbital)
7. Hypogastric pain
8. Dysuria
9. Water vaginal
discharge
10. Bloody vaginal
discharge

General Mental Status Conscious, coherent, wheelchair-borne

Weight 5’4” 145 lbs - current
● Pre-pregnancy weight (kg) BMI: 24.9
● Preg/current weight (lb)
Height
BMI (pre-pregnancy) Prepreg: 115 lb -
BMI: 19.7
Vitals BP (140/90; Sev - 160/110) BP: 130/80

Gestational HTN: ≥140/90 mmHg after 20 weeks; HR: 88
Preeclampsia: ≥140/90 mmHg after 20 weeks on 2
RR: 20
occasions at least 4 hours apart with proteinuria Temp:36.5
Chronic HTN: ≥140/90 mmHg before pregnancy or
before 20 weeks; persistent after 12 weeks postpartum
HR
RR
Temp
HEENT Conjunctiva
Sclera
Exophthalmos
Nasal discharge
Thyroid/neck mass
Cardio Precordium
Apex Beat
Heaves
Lifts
Thrills
Murmurs
Respi Chest Expansion Symmetrical

Tactile fremiti
Clear Breath sounds
Wheezes
Crackles
Breast Inspection
● Symmetry
● Gross lesion
● Skin dimpling
Palpation
● Mass
● Tenderness
Abdomen Inspection Inspection: a sharp upward

● Shape Globular
● Scar (Mcburney, Pfannenstiel/ pushing against
Suprapubic transverse incision, the uterine wall
Midline vertical incision) No scars with a finger
inserted into the
Tenderness FH - 32 cm vagina for
suprapubic pain LM1- soft nodular fetal pole (breech)
Percuss for CVA Tenderness
diagnosing
LM2 - fetal back left
LM3 - ballotable mass pregnancy by
Fundic Ht (12,16,20) LM4- negative feeling the return
impact of the
FHT: 154 bpm, regular
displaced fetus also
Uterine contractions: every 7-8 minutes, lasting ?? gugel
30-40 seconds, moderate intensity
ACT:
Ballottement - try to
hold on to that
well-rounded fetal pole
→ move side to side →
bouncing → appreciated
Leopold’s (28) when there’s adequate
● LM1 (Fundic grip) amount of amniotic fluid
● LM2 (Umbilical grip)
Uterine contractions (28-Braxton/37)

● Mild/mod/severe
● Duration
● Freq (“occurring every __”)
● Tetanic in Abruptio Placenta
● Preterm Labor - ≥4 every 20 minutes or ≥8
in 60 minutes
Fetal Heart Tone (6, 10, 18-20)
Auscultation/ Bowel sounds
CHECK FOR CVA TENDERNESS - in

flank/lower back area
Presence of Abdominal Mass/Tenderness -

abruptio placenta
Pelvic External Genitalia Ask px to void

● Inspection (Hair pattern, Lesions, Cervix 6 cm, soft, 50% effaced, midposition, station
Erythema, Discharge) -2 Compute expected date of
● Palpation (mass, inguinal Intact membranes delivery
lymphadenopathy)
Speculum Cephalic nga soo pelvimetry? Didn’t ask about watery
● Cervix = Violaceous/pink, smooth, fish/donut, Di na daw need kasi not primi ohhhh discharge and color of
discharge, erythema
● Vaginal wall = violaceous or pink discharge and if it’s
○ no need to be done in F. check-ups, unless CC Uterus: foul-smelling
is vaginal discharge, pruritus
● PPROM EDC: August 30, 2021
○ clear fluid flowing from the cervix Bishop Score: 8
○ malodorous discharge Naegele’s rule: Subtract 3
■ If no pooling or no clear fluid coming out, ask months, add 7 days to 1st
there would be passing of fluid Adnexa: day of LMP
EFW: How to compute based

Internal (NO in Previa) on fundic height if no
● Cervix + cervical motion ultrasound
tenderness
○ 1st CHECKUP: Long, Soft, closed Johnson’s Formula
○ TERM: FH - 11 or 12 x .155
● Cervix soft, long 32 - 11 = 3.2 kg x 2.2 lbs =
● Dilatation 7.04 lbs
● BOW
● Presentation If engaged = -11
● Station
○ In Labor
If unengaged = -12
■ Cervical effacement of >80% Ask about Position of the
○ To check for cervical dilatation = head: to know position of head
○ We should NOT palpate on the cervical and identify if you have
os cos might stimulate contractions progressed properly during the
○ Instead, palpate the fornices and cardinal movements of labor
check the LENGTH. Cos if long
(uneffaced), probably also closed os
■ To check for dilatation, BOW,
presentation, station
● Uterus If you can palpate for posterior
○ Don’t check for ante-/retroversion fontanel (triangular-shaped):
○ Just check for SIZE fetal head is in flexed position,
■ At umbilicus = 20 wks AOG meaning the Smallest
■ Midway (accdg to TCL): 12 wks diameter (9.5)
AOG
○ Tenderness in abruptio placenta
suboccipitobregmatic is the
one presenting
● Adnexa (if possible; only if )
● Cul-de-Sac & Fornices If bregma or anterior fontanel?
○ Ectopic Pregnancy - Deep/Bulging
- Occipitofrontalis: 12.5?
Bishop
Speculum exam: note
Pelvimetry
● Inlet:
about bloody discharge →
○ Measure diagonal conjugate (N: >11.5cm) bloody show from
○ Sacral promontory (N: not accessible) dislodged cervical mucus
○ Engaged head? plug due to uterine
● Midpelvis: contractions
○ Pelvic sidewalls (N: Divergent/ NOT When do we do this in a
convergent)
○ Sacrum curved
pregnant women in labor:
● Outlet: when px has abnormal
○ Sub-pubic arch wide >90 degrees discharge???
○ Bituberous diameter >8cm (wider than fist) - Abnormal, foul
discharge
(leukorrhea)-- to
know what type of
vaginitis
- Rupture of
membranes:
watery discharge
-
Rectal PID, Endometriosis, Endometrioma, Virgin

IF term: ADD cephalic, in labor
CC: Abdominal pain

DC, 20 year old, with live in partner, student, catholic
LMP: Nov 23
G2P1 (1001) Pregnancy uterine, 39-40 wks AOG, cephalic, in labor
Subjective salients Comments/Suggestions

(PERTINENT only to clinical impression) Objective salients
(PERTINENT only to clinical impression)
8/10 Abdominal (epigastric?) pain migrating to hypogastric No watery vaginal discharge

region and back lasting 1 minute every 15-20 minutes No headache
39-40 weeks AOG (39 wks and 4 days) No blurring of vision
Spotting on underwear after urination/(+) bloody vaginal No dysuria
discharge No fever
Uterine contractions: every 7-8 minutes, lasting 30-40 No decreased fetal movement
seconds, moderate intensity Pyuria (6-8) on 1st prenatal UA
Cervix 6 cm, soft, 50% effaced, midposition, station -2 Normal FBS, OGTT
Intact membranes No HTN, DM
History of jaundice 1st child
History of appendectomy -- not sure if important to 130/80
88
18
Family history: DM (father) 36.5
5’4”
Ilan yung contractions niya? 145 -> 24.9
115??
BMI 19.7
FH = 32 cm
FHT 154 bpm, regular
UC 30-40 seconds, every 7-8 mins, moderate
Station -2
Intact BOW
6 cm dilation
Ddx 1
Manifestations
Why Rule In Ddx: Labor
Why Rule Out
Ancillaries
Management
RULE IN RULE OUT
Increasing abdominal pain

39-40wks AOG
Bishop score 10 or 8?
Contraction every 7-8 mins, 30-40
seconds
Cervix dilated to 6cm
(+) bloody discharge (bloody show)
Ddx 2
Manifestations
Why Rule In Ddx: Braxton Hicks?
Why Rule Out
Ancillaries
Hypogastric pain Patient’s contractions are long (BH is

shorter)
Patient’s contractions are regular (BH is
irregular)
Patient has radiation of pain (BH has no
radiating pain)
Ddx 3
Manifestations
Why Rule In Ddx: Abruptio placenta not suuuure if nagask lang siguro si doc ng iba pa?
Why Rule Out
Ancillaries
Vaginal bleeding (spotting) FH < AOG

Abdominal pain (-) abdominal tenderness
BP: 130/80 mmHg Contractions are not tetanic
Suggestions
For Baseline Q: What stage of labor

Ancillaries ● CBC (N in preg: ≤14,000-16,000 CBC is she in?
WBC) Blood typing and crossmatching - possible ● 1st stage of labor
● Blood Typing (and of partner) blood transfusion? ● At active phase (6
● Urinalysis
Urinalysis cm dilatation)
● FBS
● HIV (3rd trim) RT PCR swab
● HBSAG (3rd trim) Q: What are the phases
● VDRL/RPR (3rd trim) Labor Admission Test of 1st stage of labor
Ultrasound ● Using electronic fetal monitor (EFM) to ● Acceleration
● Ectopic - Ring of Fire check if the fetus can handle the (4-6cm)
● H-mole stress of labor ● Maximum slope
○ Complete - Snowstorm ○ initial CTG done upon admission (6-8cm)
○ Incomplete - Thickened of pregnant women in labor. If ● Deceleration
multicystic placenta with fetal
initially upon admission, there (9-10cm)
tissue
are decelerations or category II
(Non-reassuring), do not wait for
BPP and Congenital Anomaly Scan
labor, intervene sooner and do
(24 weeks AOG)
CS
● To check for baseline fetal heart rate,
check for accelerations, decelerations
and uterine contractions
● Intrapartum fetal monitoring:
○ Pt is at = 1st stage of labor and
low-risk pregnancy: every 30
mins
○ (2nd stage of labor: every 15
mins)
● Normal FHR: 110-160 bpm
Baseline FHR: 140-150

Variability: moderate (5-25 bpm inc)
Accelerations: (+)
Decelerations: (-)
Uterine contractions: every 3-4 mins, 50-60
seconds duration, moderate (80) = true labor
Category 1, Normal Tracing / Reassuring

Plan: Proceed with expectant management → go
on with labor
Other possible labs (to prepare preventive

measures for fetal intrapartum transmission, and
protection for health personnel:
● HBsAg
● RPR
Treatment 1st trimester Check bishop score 10 Yes parang di na need

HPN in preg ● Folic Acid - .4mg/4mg (1 month prior to i mean di na need cervical ripening kasi ng ripening
Aspirin
● TCL: stock dose/for pt pregnancy - 14 wks) favorable for induction na tama po ba?
with HPN: 80mg (for ● Multivitamins 1 tab OD Cervical ripening Magiinduce [a ba e
doctors Dinoprostone Gel nagllabor na yes
trimester (best time) ● Multivitamins 1 tab OD Route/Dose: Cervical/0.5 mg of Dinoprostone
Ca supplement ● Calcium carbonate/Milk ■ Remain recumbent for 30 minutes after
● to prevent chronic HPN application S2-s4: pudendal: vulvar
to progress ino
preeclampsia 24-34 weeks ■ Give every 6 hours for a maximum of 3 doses in If uterine contractions,
● Betamethasone 12 mg given IM 24 hours 24 hours − Oxytocin should be infused 6 hours or higher in the thoracic
GDM
● Monitor 2 weeks if diet apart for 2 doses more after administration and not earlier because i area . Review ob
and exercise can control ● Dexamethasone 6 mg given IM every 12 analgesia
insulin Labor induction (not do anymore since patient is in
24-32 weeks active labor) 2 minutes to 8!
● MgSO4 - upto 32 wks only 10-20 mU/mL oxytocin concentration
● IV (4-1): 4g slow IV push via infusion Oxytocin 1-2 ampules (10-20 units) diluted in 1L
pump for 20-30 mins then 1-2 g/hr for 24 NSS or LRS
hours or until delivery whichever comes
first If contractions are not adequate (< 200
● IM (4-5-5): 4g slow IV push via infusion Montevideo units), and if the fetal status is
pump + 5g IM on each buttock then 5g
reassuring and labor has arrested, an oxytocin
IM alternating per buttock 4 hours apart infusion dose greater than 40 mU/min has no
apparent risk
No need to give oxytocin because good uterine

contractions and reassuring fetal status
Offer some form of OB analgesic (epidural)

This is stronger Epidural anesthesia, offer at
the end of delivery - to make patient
comfortable since there are uterine
contractions
Delivery
Vaginal delivery
Follow-up schedule Advice to watch out for danger signs Post partum +4/+5 = can already
of pregnancy Rooming in - put baby beside mother in room; ask patient to do
to promote early breastfeeding valsalva maneuver
Advice for ff-up:
● Normal Pregnancy Maternal monitoring every 1-2 hrs then every 4 Episiotomy
○ <28 weeks - hrs after 24 hrs
monthly - Routine vital signs regularly Something maneuver -
○ 28-36 weeks - - Fundal check to check for fundal tone (if Ritgen’s maneuver
every 2 weeks may atony or not)
○ >36 weeks - every - Check presence of vaginal bleeding EINC
week - Retest CBC
● High-risk preg - Perineal care - sitz bath?
○ More frequently - Continue analgesics for pain (opioids)
○ Every 1-2 week - Laxatives/ stool softeners - for better and
intervals less pain in wound healing
- Encourage continuing breastfeeding
- Routine immunizations if needed eg
MMR, Tdap

Suggestions
Admission date - August 24, 2021 10:00 AM Admit to Delivery Room Low risk monitoring of
Name - E.A. Diet NPO VS: every 30 minutes
Age - 34 yo G1P0 7-8 wks AOG Maintain on bed rest
Monitor vitals every 30 mins Need rin ba monitor
Diagnosis - G1P0 Acute Abdomen secondary to Ectopic Urine input and output yung baby?
Admit - Direct to OR Every 15 mins in

Diet - NPO second stage of labor
Monitor - Monitor HR, RR, Temp, O2 sat every 30min
Refer accordingly
Repeat UA
Repeat OGTT
delay (should be around 9 cm), so they gave oxytocin to enhance labor
Early decel normal bc there might be a bit of head compression bc fetus descended
Patient underwent normal labor

Instruction for patient at Head at station +4 and 5: do valsalva maneuver so head can be expelled already. Do episiotomy
CARES Notes
Bishop Scoring
3,2,1,1,i
Fetal Growth/IUGR
TSH Thyroid Labs

HEADSSSS

Twin Pregnancy
General Data
ACT: Introduce yourself as part of the medical team, like “kasama po ako ng residente…” (to build rapport!)
Name: ST Age: 29 Birthday: Address: Paranaque
Civil Status: Married(Med rep husband) # Years married: Nationality: Fil
Education: Occupation: Nurse, (on leave) Religion: Catholic

Husband: Med Rep
Chief Complaint: “Kumakati sa pwerta” Vaginal Pruritus Comments/Suggestions
HPI
If Pregnant/suspicious of preg: Onset:1week ago start 7+31+26= 9-10 weeks

L - sa loob ng pwerta
● Presumptive symptoms D-
○ Morning sickness (6-18) C- Check for dm symptoms
○ Idiosyncrasies of taste and A - no dysuria, no pain, with white mucoid non-foul discharge
smell
○ Fatigue R- Ask for dysuria later
○ Urinary frequency, nocturia (1st T- continuous Ask if with discharge -
& 3rd trimester) Severity: 4-5/10 (last week) 7-8/10 (now) Ask if may diabetes
○ Amenorrhea
OCP intake/ prolonged
○ Skin changes No pregnancy test done antibiotic intake
○ Increased temp (6)
○ Quickening (P-18-20; M-16-18) Presumptive Signs: Nausea and vomiting?
● Probable signs
○ Abdominal enlargement (12) ● N&V Frequency in urination
○ Braxton Hicks (28) ● Missed menses
1. Headache
4. Fever and chill
periorbital)
7. Hypogastric pain
8. Dysuria

● Onset
● Location
● Duration
● Character
● Assoc/Aggrav
● Allev
● Rad
● Tempo/Timing
● Severity
● Where
● When last ff
● How many
● Weight gain
● Assessment
● Labs & Results
fetus, placenta
LMP: June last week Comments/Suggestions

PMP:
AOG (if ever): 9-10 weeks
MIDAS Menarche M - 11 y.o PMP need ba ask since

If TERM preg: focused hx Interval I - Irregular 28 days shortest; 3 months longest irregular??
na (“Your patient has big
D - 3-4 days
Amount
tummy, who cares of A - 3-4 regular napkins, moderately soaked
Symptoms
menarche”) S - none
OB Hx G: 1 P: 0 TPAL:
If Pregnant AOG: 9-10 weeks EDC:
OB HX
Sexual hx Coitarche 21 years old

# of Partners 1
Job of partners Med rep (husband)
Last sexual contact
Post Coital bleed None
Dyspareunia None
Family Planning None
Past Medical hx Comorbids (HTN/DM/Thyroid) Unknown

Medications
Surgeries
Transfusions
Hospitalizations
Immunizations COVID-19, no flu, no HepB
Prev Prenatal Check up No previous check up
Personal & Social hx Smoking None

Alcohol None
Drugs None
Diet
Exercise
Family hx DM (+) DM (+) HTN (+) Thyroid dx- mother

HTN (+) Colonic Cancer - grandfather
Cancer
Asthma
Thyroid disease
Blood dyscrasia
Seizure
Heart disease
General (-) Weight Changes, (-) Changes in appetite, () Fever, () Chills, (-) Sleep Changes, No danger signs of
HEENT (-) Headache, (-) Blurring of Vision, () Exophthalmos pregnancy
Cardio (-) Palpitations, (-) Easy fatigability
Pulmo (-) Cough, (-) Colds, () Dyspnea, () Chest pain
.(-) Polydipsia, (-) Polyuria,
(-) Polyphagia
Melena
Endocrine (-) Polydipsia, (-) Polyuria, (-) Polyphagia, () Heat intolerance, () Cold intolerance, () Irritability
Prenatal Check up)
1. Headache
4. Fever and chill
5. Nondependent
Edema (hands,
periorbital)
7. Hypogastric pain
8. Dysuria
9. Water vaginal
discharge
10. Bloody vaginal
discharge
General Mental Status Conscious and coherent

Weight
● Pre-pregnancy weight (kg) 102lbs
● Preg/current weight (lb) 100lbs
Height 5’2
BMI (pre-pregnancy) 18.7 prepreg (18.3 current)
Vitals BP (140/90; Sev - 160/110) BP 110/80

Gestational HTN: ≥140/90 mmHg after 20 weeks; HR 84bpm
RR 18rpm
occasions at least 4 hours apart with proteinuria Temp 36.5
HR
RR
Temp
HEENT Conjunctiva pink palpebral conjunctiva

Sclera Anicteric sclerae
Exophthalmos
Nasal discharge
Thyroid/neck mass
Cardio Precordium Adynamic precordium

Apex Beat 5th LICS MCL
Heaves No heaves, lifts, thrills
Lifts No murmurs
Thrills
Murmurs
Respi Chest Expansion Symmetrical Symmetrical chest expansion

Tactile fremiti Clear breath sounds
Resonant to percussion No use of accessory muscles
Clear Breath sounds
Wheezes
Crackles
Breast Inspection Symmetrical

● Symmetry No lesions, dimpling
● Gross lesion
● Skin dimpling (-) discharge
Palpation (-) mass, tenderness
● Mass (-) lymphadenopathies
● Tenderness
Abdomen Inspection Inspection: abdomen is flat

● Shape Auscultation: Normoactive
● Scar (Mcburney, Pfannenstiel/ Palpation: No mass, tenderness
Suprapubic transverse incision, (-) CVA tenderness
Midline vertical incision)
Tenderness
suprapubic pain
Fundic Ht (12,16,20)
Leopold’s (28)
● LM1 (Fundic grip)

● Mild/mod/severe
● Duration
in 60 minutes


abruptio placenta
Pelvic External Genitalia External:

● Inspection (Hair pattern, Lesions, ● Inverted triangle LNR comments:
Erythema, Discharge) ● No erythema
● Palpation (mass, inguinal ● No mass, lymphadenopathy - Ask character of
lymphadenopathy) discharge
Speculum Speculum: - Complete PE
● Cervix = Violaceous/pink, smooth, fish/donut, ● Cervix - violaceous, smooth, donut shaped (examine
discharge, erythema
● Vaginal wall = violaceous or pink ● Discharge adherent to the walls extremities)
○ no need to be done in F. check-ups, unless CC - 9-10weeks ask if
is vaginal discharge, pruritus the uterus slightly
● PPROM
enlarged (not if it
○ clear fluid flowing from the cervix is at the
○ malodorous discharge symphysis)

tenderness Cervix is long, soft, and closed
○ TERM:
● Cervix soft, long
● Dilatation
● BOW
● Presentation
● Station
○ In Labor
○ To check for cervical dilatation =
○ We should NOT palpate on the cervical
os cos might stimulate contractions
○ Instead, palpate the fornices and
● Uterus
○ Don’t check for ante-/retroversion
○ Just check for SIZE Anterverted, size (not near symphysis pubis)
■ Midway (accdg to TCL): 12 wks
AOG
● Adnexa (if possible; only if ) No tenderness or adnexal mass
Bishop
Pelvimetry
● Inlet:
○ Engaged head?
● Midpelvis:
convergent)
○ Sacrum curved
● Outlet:

Primigravid, early pregnancy at 9-10 wks AOG by LMP, vulvovaginal candidiasis

● 29y/o primigravid ●
● Came in due to continuous vaginal pruritus from ● Speculum: Cause of Candidiasis ruled
4-5/10 to 7/10 Cervix: violaceous, smooth, donut shaped out
● (-) dysuria, (-) pain with visible discharge adherent to walls ● (-) OCP intake
● (+) White vaginal discharge, curd like? (thick), ● (-) DM
non-foul ● Antibiotic intake (not
● (+) Adherent sa walls! asked)
● No danger signs of pregnancy
Early preg = nausea (morning sickness) LNR: (Kung sino man

CARES)
● Not clear on what
you want to know
(language barrier)
● Missed a lot with
PE
● Patient is
complaining of
itchiness - did not
ask for the
character (just
asked if adherent
to the wall)
● Extremities
weren’t examined
● At this AOG, ask
if the uterus is
slightly enlarged
and not “at the
level of the
symphysis pubis”
● Don’t put PUL
● Should have
asked in Hx/PE if
the discharge is
curd-like or
cottage cheese
like in
appearance, and
if thick or not
● Need to correlate
what is asked in
● Ask word for
word, ilicit
Ddx 1 Curd like is not asked
Manifestations
Why Rule In Ddx: Candidiasis
Why Rule Out
Ancillaries
Management
RULE IN RULE OUT
(+) Curd Like whitish vaginal discharge

(+) Adherent to the vaginal walls
(+) non foul
(+) Pruritus
(+) Pregnant - risk factor
(+) Family history of Diabetes
Ddx 2
Manifestations
Why Rule In Ddx: Trichomoniasis
Why Rule Out
Ancillaries
With pruritus (but lesser than Yellowish/creamy/ greenish discharge (Pt

candidiasis) had white discharge)
(-) Odor Dysuria (pt had no dysuria)
Multiple sexual partners (Pt had only 1
sex partner = husband)
Check for Strawberry Cervix
(-) Dyspareunia
(-) Whiff test
Ddx 3
Manifestations
Why Rule In Ddx: Bacterial Vaginosis
Why Rule Out
Ancillaries
Whitish-gray discharge Thick discharge (usually thin)

No odor
Suggestions
Ancillaries For Baseline For vaginitis Pathophysiology of

● CBC (N in preg: ≤14,000-16,000 ● CLINICAL diagnosis fishy amine odor:
WBC) Release of aromatic
● Blood Typing (and of partner) If nag ask lang: amines
● Urinalysis
● Wet mount using 10% KOH (trimethylamine) upon
● FBS
● HIV (3rd trim) ○ Look for hyphae/mycelia 10% KOH
● HBSAG (3rd trim) ● pH of vagina
● VDRL/RPR (3rd trim) LNR:
Ultrasound For PNCU: ● Manage your
● Ectopic - Ring of Fire ● CBC patient
● H-mole ● Blood typing with Rh holistically
○ Complete - Snowstorm ● Urinalysis don’t forget
○ Incomplete - Thickened ● FBS prenatal care
● Transvaginal Ultrasound - confirm diagnostic
tissue
pregnancy, establish AOG, check labs esp if 1st
viability of pregnancy (most check-up
important reason why TVS is ● Marker of
(24 weeks AOG)
viability:
requested right now), location and Cardiac
number of fetus, (since we considering activity
early preg) (evident at
6-7wks aOG)
● Should have
asked if there
was intake of
antibiotic
which may be
contributory to
VVC
●
Treatment 1st trimester For Candidiasis:

HPN in preg ● Folic Acid - .4mg/4mg (1 month prior to Miconazole 100mg vaginal suppository, once Vulvovaginitis
Aspirin
● TCL: stock dose/for pt pregnancy - 14 wks) daily for 7 days, at bedtime - Miconazole will
with HPN: 80mg (for ● Multivitamins 1 tab OD (avoid oral due to potential risks of azole therapy in only treat
doctors pregnancy) vaginitis
trimester (best time) ● Multivitamins 1 tab OD
Ca supplement ● Calcium carbonate/Milk Prenatal supplement: For vulvar pruritus: give
● to prevent chronic HPN - Folic acid 400micrograms 1 tab PO per a topical cream
to progress ino
preeclampsia 24-34 weeks day until end of 1st trimester (14
● Betamethasone 12 mg given IM 24 hours weeks)
GDM
● Monitor 2 weeks if diet apart for 2 doses
and exercise can control ● Dexamethasone 6 mg given IM every 12 Prognosis: Vaginal candidiasis is not associated Nystatin or
insulin with adverse pregnancy outcomes Clotrimazole daw
24-32 weeks pwede both cream
● MgSO4 - upto 32 wks only Prescription:
● IV (4-1): 4g slow IV push via infusion ● Miconazole 100 mg suppository #7 Clotrimazole
pump for 20-30 mins then 1-2 g/hr for 24 Insert suppository high at vagina once a day
hours or until delivery whichever comes at bedtime for 7 nights. Avoid coitus pwede ba
first to dito
● IM (4-5-5): 4g slow IV push via infusion
Brand: Neopenotran
Proper perineal hygiene
● Wash with mild soap
● Wear cotton underwear, avoid tight
underwear and pants
● Wipe from front to back
● No douching? Washing or soaking
cleaning the inside of the vagina using
pressure? Using water and other mixtures
● Do not put any irritating substances such
as lotions, creams
Avoid coitus (since intravaginal infection and

vaginal suppository)
Monitor danger signs of pregnancy

● Vaginal bleeding (possible abortion
since 1st trimester)
● amd watery vaginal discharge
● Persistent headache
Follow-up schedule Advice to watch out for danger signs Follow-up after release of laboratory results
of pregnancy
Advice for ff-up:

● Normal Pregnancy
○ <28 weeks -
monthly
○ 28-36 weeks -
every 2 weeks
week
● High-risk preg
○ More frequently
○ Every 1-2 week
intervals

Suggestions
Admission date - August 24, 2021 10:00 AM

Name - E.A.
Diet - NPO
Refer accordingly
CARES Notes
Bishop Scoring
Fetal Growth/IUGR
TSH Thyroid Labs

HEADSSSS

Twin Pregnancy
OB ESGD: Preeclampsia with Severe Features
Date: August 26, 2021 (Thursday)
Facilitator: TBM
SCRIPT
INTRO AND GEN DATA

● Good afternoon, ako po si, clinical clerk ____. Narito po ako para kunin ang history ninyo.
● Ano po ang kumpletong pangalan ninyo? Ano po ang gusto nyong itawag ko po sayo?
● Married or single?
○ Ilang taon na po kayo kasal?
● May anak na po ba?
● Ano po ang inyong nationality?
● inyong relihiyon?
CC:
● Ano po ang dahilan bakit kayo nagpakonsulta ngayon?
HPI:
MISSED MENSES:
● Kelan ba ang huling regla mo? Ito ba yung normal na usual na regla mo, or napansin mong mas kaunti?
● Regular ka talaga bwan bwan?
○ Nahihilo? Nagsusuka? Parang nasususka? Sinisikmura? Ihi ng ihi? Yung dede mo ba nararamdaman mong
medyo masakit?
● Nasubukan mo na ba magpregnancy test?
If Gyne:
● Hindi ka ba nastress nitong mga nakaraang araw? Hindi ka biglang nag exercise ng todo todo? Wala ka namang biglang
weight gain or weight loss? Hindi ka madaling lamigin or mainitan? Walang pakiramdam na laging pagod? Palpitations?
● Wala kang nararamdamang masakit sa may puson? Nakakapang bukol? Or nararamdamang mabigat?
● May tinatake po ba kayong mga gamot?
PRENATAL CHECK UP
● Signs of labor:
○ May nararamdaman na po bang contractions (o paninigas ng tiyan)? Gaano po katagal yung contraction and
gaano katagal yung pagitan ng dalawang contractions?
○ Hindi ka naman Nahilo?
○ Walang problema sa paningin?
○ Hindi ka dinudugo
○ Walang kahit anong lumalabas sa puwerta?
If DM mommy:
ABDOMINAL PAIN
● Duration: Gaano po katagal nyo nararamdaman ung pagsakit? Mga ilang minuto po sya masakit? After po nitong _ mins
nawawala na or may mild pain pa rin po?
● Severity: Kung irate nyo po yung pagsakit into 1-10, 1 bilang pinakamababa at 10 bilang pinakamataas? Mga gaano po ito
kalala?
● Temporal: may specific na oras po ba kung kelan nyo nararamdaman? Pagkakain? gabi o umaga? (if 45+ nagreregla pa
ho ba kayo ngayon?) Kailan nga ho ang huling regla nyo? Hindi sya sumasakit pag nireregla? Mga ilang araw po
pagkatapos ng regla nyo nararamdaman yung sakit?
● Aggravating: May napansin po ba kayong nagpapalala ng inyong nararamdaman? Pag umuubo, pag nagbubuhat?
● Relieving: Ano pong ginagawa nyo para mawala po ung sakit? May iniinom po ba kayo na gamot? Basta ho ba nawawala
yung sakit? Hindi ho kailangan madumi kayo o mautot or maihi para mawala yung sakit?
● Associated: May iba pa po ba kayong nararamdaman paglalagnat pagsusuka pagkahilo panghihina mabilis mapagod?
May abnormal po bang discharge na nakikita sa panty? wala naman po kayong nakakapang parang bukol sa may tyan
nyo?
● Nakapagkonsulta ka na ba dati nung nakaramdam ka nang ganyan? Ano ho sabi ng doctor? May nireseta ba sayong mga
gamot?
VAGINAL DISCHARGE:
● Character: Pano nyo po idedescribe yung discharge? Malagkit ho ba o parang matubig tubig lang? Sa kulay po, maputi po
ba, maberde, mabbrown or parang may dugo dugo? Sa amoy ho? Parang mabaho po ba? Malansa o wala namang amoy?
Gano ho karami tong discharge na to? Nagpapanty liner po ba kayo? Ngayong may discharge po kayo nakakailang palit po
kayo ng pantyliner?
● Duration: Ilang buwan na po kayong may discharge na ganyan? Napapansin nyo po sya araw araw? First time nyo lang po
ba ito maexperience? Dati ho walang mga ganyang discharge?
● Aggravating: May ginagawa po ba kayo bago nyo mapansin tong discharge? Kagaya ng katatapos nyo lang makipagtalik,
o pagkatapos ng regla? Kung irerelate po sa regla ilang days po after ng regla nyo sya napapansin?
● Associated: Hindi naman po kayo nilalagnat? Walang pangangati sa pwerta? Walang masakit sa bandang pwerta o sa
tyan? Hindi masakit ang pag-ihi? Hindi ho sya sumasakit pag nagtatalik? Wala kayong napapansing tumutubo sa pwerta?
○ Fever: Kailan ka naglagnat? Ano pinakamtaas na temp ang nakuha mo? May ininom ka bang gamot para sa
lagnat? Wala bang ubo at sipong kasama yan?
○ Dyspareunia: Tuwing kelan sumasakit? Sa pagpasok ba ng ari? Sa buong oras na nagtatalik o pagkatapos na ng
pagtatalik?
○ Dysuria: kelan nagsimula sumakit ang pag ihi mo? tuwing kelan sya sumasakit? Sa unang pag ihi, sa gitna ba o
pagkatapos? Kamusta ang pag ihi mo ngayon? Ano ang ginagawa mo para mawala ang sakit? Narerelieve ba?
ABNORMAL UTERINE BLEED

● Onset: Kailan pa po nagsimula? Tuloy tuloy lang po ba ang pagdudugo? Hindi po sya tumigil?
● Character: Pano po yung pagdudugo? Spotting lang po ba or marami? Nakakailang pads po kayo per day? Regular or
night pads? Napupuno po ba?
● Aggravating: May napapansin ka bang mga gawain na nagpapalala ng pagdugo?
● Relieving: May ginagawa ka ba para mawala yun or mabawasan?
● Associated:
○ Di naman nahihilo? Pamumutla? Headache?
○ Dysmenorrhea: Nakakaranas po ba kayo ng pagsakit ng puson dahil dito? Tuwing kelan?
○ Infertility: Nagtatry ho ba kayo ni mister na makabuo ng anak? Gano katagal na po kayong nagtatry?
○ epistaxis, bruising, gum bleeding, postpartum hemorrhage and surgical bleeding (pagdugo ng ilong at gilagid, labis
na pagdugo pagkatapos manganak?, nasalinan ba kayo ng dugo (if may past surgery)
○ Hypothyroidism s/sx: Weight gain, cold intolerance, constipation, bradycardia (Sumikip ba yung damit, madali
lamigin, hirap sa pagtae, sa PE na yung brady)
● Temporal
● MENSTRUAL HISTORY: Kailan po ang unang araw ng huling regla nyo? Regular po ba kayo nireregla? Ilang araw po ba
ang usual na tinatagal? Nakakailang napkin ka per day?
○ M - Ilang taon po kayo nung una kayong niregla?
○ I - Regular po ba kayo nagreregla? Kunyari ho July 10 niregla kayo, kailan po ninyo ineexpect ang susunod nyong
regla?
■ If irregular: mga gaano po katagal na hindi kayo nireregla? Mga ilang bwan po kayong hindi dinadatnan?
○ D - Ilang araw po ito nagtatagal? Sa _ na araw na to, kasama na po ba yung mga pahabol na regla?
○ A - Ilang pads po ang nagagamit nyo kada araw ng regla? Ano po ang gamit nyo regular pads o night pads? Fully
soaked pads po ba to? May buobuo po bang dugo kayong napapansin (blood clots)?
○ S - May nararamdaman po ba kayong sintomas tuwing dinudugo? Sakit sa puson, pagkahilo, pagsusuka?
AMENORRHEA
● Onset: Kailan niyo po napansin na tumigil na yung pagmemens nyo? (differentiate primary: no mens ever til 15 y/o from
secondary: no mens 6-12 months)
● History of UTI: Madalas po ba kayong nagpapacheck up dahil sa masakit na pag ihi? Ano po yung payo ng doctor sa inyo?
(ask if primary ameno)
● Associated s/s:
○ Weight loss: (Napansin niyo po ba kung namayat kayo? Alam niyo po ba ang usual body weight nyo? Napapansin
niyo po ba kung nagsiluwagan yung mga damit niyo?)
○ Tumor mass effects: headache, blurring of vision (prolactinoma)
● Ask for Danger signs of pregnancy


Napansin nyo po bang biglang bumaba ang timbang ninyo? May pagbabago po ba sa inyong pagkain? Pagtulog? Mabilis ba kayong
mapagod? Wala naman po ubo, sipon, hirap sa paghinga? May pagbabago po ba sa pagdudumi? Sa pagihi? Napansin nyo po ba
kung madali kayong magkapasa o namumutla po ba kayo? Di naman po palaging uhaw o gutom? Hindi naman init na init o
nanlalamig?
If you want specific use this, but if not then skip

1. General or constitutional Napansin mo bang pagbabago sa timbang (for sure meron kasi buntis), panghihina?
symptoms pagkawalang gana sa pagkain? pagbabago sa pagtulog?
2. Skin/ Hair/ Nails may napapansin po ba kayong nakakaiba or nararamdaman sa kahit anong parte ng
inyong balat? Nakakaranas ka ba ng pangangati? May mga rashes ba?
3. Head and Neck EYES: Walang naman problema sa paningin?

Walang panlalabo ng paningin? pagkaduling?
MOUTH: Pagdudugo sa gilagid?, pagkawala ng panlasa?
NECK: May napansin po ba kayong bukol sa may leeg?
4. Breasts Nagseself breast exam po ba kayo? If yes, May nakakapa po kayong bukol? Discharge?
May lumalabas na gatas?
5. Pulmonary - ask for COVID Wala namang ubo? Sipon? hindi hirap sa paghinga? Pananakit ng dibdib?
6. Cardiac May napansin po ba kayong pagbilis sa pagtibok ng puso? Madaling mahingal?

7. Abdominal Wala naman pong pananakit ng tyan? Wala naman po pagbabago sa pagdudumi? Hindi
po ba kayo hirap dumumi ngayon? Araw araw naman po? Walang dugong napapansin? Di
naman po ito matubig? Diarrhea?
8. Genitourinary Napapansin nyo po bang kakaiba sa inyong pagihi tulad ng madalas na pag-ihi?
Bumabangon po madalas sa gabi para umuhi? Hirap sa pagihi? May pakiramdam na di
kumpleto ang pagihi?
9. Hematologic Walang abnormal na pagdudugo, pagpapasa, at pamumutla?
10. Endocrine - check for GDM Hindi ka naman palaging uhaw? Gutom? Hindi laging init na init o lamig na lamig?
11. Musculoskeletal May nararamdaman po bang pananakit ng katawan?
12. Neurological Sumasakit po ba ang ulo ninyo o Nahihilo? (already asked sa HPI)
13. Psychiatric Pagkanerbyos? May napapansin ho ba kayong pagbabago ng inyong mood? O may
nararamdamang depression?
MENSTRUAL HISTORY
LMP - Kailan po ang unang araw ng huling regla nyo? Yung regla po bang to parang yung usual nyo o parang spotting lang?
● I - Regular naman po ba ang regla nyo? Mga ilang araw po ang pagitan? Kunyari ho April 5 niregla kayo, kailan po ninyo
ineexpect ang susunod nyong regla?
○ If irregular: mga gaano po katagal na hindi kayo nireregla? Mga ilang bwan po kayong hindi dinadatnan?
● A - Ilang pads po ang nagagamit nyo kada araw ng regla? Ano po ang gamit nyo regular pads o night pads? Napupuno po
ba to? May buobuo po bang dugo kayong napapansin (blood clots)?
● S - May nararamdaman po ba kayong sintomas tuwing nagreregla? Tulad ng sakit sa puson, pagkahilo, pagsusuka?
Tuwing anong araw po ito ng regla nangyayari (may iniinom po ba kayo na gamot? Nawawala po ba?)
OB HISTORY
● G: Ilan na po ang anak ninyo? Nakunan na ho ba kayo? Pagbubuntis sa labas ng matres? Kasama na po ba to dun sa
___? So bale ___ po lahat? Wala po yung tulad ng kyawa? Yung ___ po na anak ninyo kamusta naman? kasama nyo po
ba lahat sa bahay? Ask for history of congenital anomalies na din if high risk
● Lahat po ba to ay nasa kabwanan (term or preterm)? Naalala nyo po ba kung ano timbang nila? Lahat po ba to normal
delivery or may Cesarean po kayo? (bakit po kayo naCS?) San po kayo nanganak? (Ano hong ospital?) Sa lahat po ng
pagbubuntis, may naging komplikasyon po ba nung (High blood, diabetes)? Ang baby po okay naman walang naging
komplikasyon?
● Nung nakunan po kayo, ano pong year ito? Naraspa ho ba kayo? (Lumabas na lang po lahat?) Ilang buwan po ito?
SEXUAL HISTORY
Pasensya na ma’am, medyo sensitibo at personal lang po ang mga susunod ko na itatanong pero kailangan po kasi itanong dahil
kasama po ito sa history taking.
● Occupation of sexual partners: Ano po ang trabaho ng partner nyo ngayon. Elicit promiscuity of patient (risk factor for
STDs like HIV)
● Regularity/Last contact: Ngayon po, sexually active kayo? Mga ilang beses po kayo nagcocontact sa isang linggo? Kelan
po ang huling contact nyo? Gaano katagal na po kayo nakikipagtalik ng inyong partner? (how long the relationship lasted)
● Symptoms: May napapansin po ba kayong sintomas tuwing nakikipagtalik kayo? Tulad ng pagdudugo pagkatapos (post
coital bleeding), o masakit po ba tuwing nakikipagtalik (dyspareunia) - if yes, ask if insertional or pag nilalabas, o kaya bigla
po kayong nagkakadischarge na may amoy o malansa?
● Family Planning Methods: Tanong ko lang po if gumagamit kayo ng family planning method? Tulad ng contraceptives pills
o condom? Gaano katagal nang ginagamit? (Kahit dati po hindi kayo gumagamit? natural method po kayo? Ano po
ginagamit nyo? (withdrawal, calendar, abstinence?)

● Diet & Exercise

● Comorbidities: May ibang sakit po ba kayo tulad ng hypertension, diabetes, asthma, TB, sakit sa thyroid, Stroke, Cancer,
Gout, nadiagnose ng PCOS?
● Immunizations: Nabakunahan na po ba laban sa cervical cancer o HPV vaccine? Nagkaroon na po ba ng flu vaccine?
● Current Medications/Supplements: May mga gamot po ba kayong iniinom ngayon? Para saan po ito? Generic name,
brand, dose? Self-prescribed/ doctor prescribed? [If HTN or DM, ask if controlled BP or blood sugar level]
● ASK FOR PREVIOUS PRE-NATAL CHECK UPS?
● Nakakapagblood chem po ba ayo taon taon? Nakakapagpacheck po ng dugo?
● Ask for any ancillaries if available like TVS or labs
● Important to ask for Ultrasound results esp early ultrasound para make sure yung AOG
FAMILY HISTORY
● Sa pamilya naman po ninyo, Meron po bang lahi ng dyabetis, high blood, Thyroid Disorders (goiter), cancer, sakit sa dugo,
asthma, TB? Heart attack o sakit sa puso? Na-stroke? Wala naman po sa pamilya ang may problema din sa pagreregla?

!! GO straight to Focused PE table !!

Click here to skip → FOCUSED PHYSICAL EXAMINATION
-------------------- INPUT DATA HERE --------------------
GENERAL DATA
Name Remi Garcia Religion Catholic Gravida 1
Age 36 Occupation Office work Address Pasig Para 0

(WFH)
Birthday Nationality Filipino Educational TPAL

attainment
Birthplace Civil Status Married Contact no.

(2 years)
CHIEF COMPLAINT Masakit sa sikmura and masakit ulo
HISTORY OF PRESENT ILLNESS
Onset Headache and localized epigastric pain

Location O- Last night 10 pm
Duration L- epigastric only; forehead, temple, a bit occipital (HA)
Character D-
Associated Symptoms
C- Feels heavy “mabigat”
Aggravating Factors
Alleviating factors A- no n&v, no BOV, no dysuria, no discharge
Time R- ate crackers but no relief (epigastric pain); paracetamol once no relief
Severity (headache)
Medications T - continuous
S - last night (4/10) → 7/10 now (headache)
No danger signs aside from headache

1st PNCU: 6-7 weeks (private OB)
UST OPD: 9-10 weeks
● CBC:
○ Hgb 117
○ Hct .37
○ WBC 11.9
○ PMNS 0.98?; Lymph 0.19
○ Plt 313
● UA: Normal
● FBS 82.1 mg/dL
● TVS: single live IU pregnancy, 9 wks 4 days, normal sized ovaries
● Given folic acid, compliant
13-14 wks: unremarkable
21-22 wks: unremarkable
25-26 wks: 130/80, magpahinga daw → 130/80;
● OGTT: NORMAL
Normal PNCU
(+) fetal movement
Currently 31-32 wks AOG
REVIEW OF SYSTEMS
General or constitutional symptoms -
Skin/ Hair/ Nails
Head and Neck
Breasts
Pulmonary -
Cardiac -
Abdominal
Genitourinary -
Hematologic
Endocrine
Musculoskeletal
Neurological
Psychiatric
MENSTRUAL HISTORY
LMP January 19-22, 2021 PMP Dec 25-27, 2021
Menarche y/o Interval days
Duration days Amount

Soaked
Blood clots
Symptoms +
Medications
OBSTETRIC HISTORY
GP(TPAL) Gravidity: 1
Parity: 0
G1 (Year):
● BB boy/girl?
● AOG
● BW
● NSD or C/S
○ Indication:
● Where:
● Complications:
G2 (Year):
● BB boy/girl?
● AOG
● BW
● NSD or C/S
○ Indication:
● Where:
● Complications:
SEXUAL HISTORY
Coitarche yrs old # of partners Total:

Occupation:
Regularity:
Last contact: 2 mos ago
Family planning none Symptoms Post-coital bleeding: none

methods Dyspareunia: none
Smoking never
Alcohol none
Illicit drugs none
Past surgeries, no
hospitalizations, transfusion
Injuries/ Accidents -
Obstetric & gynecological Pre-natal check-ups

procedures
Allergies -
Immunization HPV:
DPT: (-)
FLU: (-)
COVID: (+) fully vaxxed 3 weeks ago
Comorbidities none
Medications Vit C, Folic acid, Iron
FAMILY HISTORY
DM, HPN, asthma, thyroid HTN -BOTH PARENTS

diseases, PCOS, cancer, DM - GRANDMOTHER FATHERS SIDE
blood dyscrasias
No exercise
Good family, work, and friend relationship
FOCUSED PHYSICAL EXAMINATION
General Survey Conscious, coherent, ambulatory, not in respiratory distress
Vital Signs BP: 160/120 **In pt. Presenting with headache, epigastric pain, can
HR: 76 check VS first. Upon knowing HTN emergency do not
RR: 19 finish PE, ONLY DO lungs heart, abdominal PE and
Temp: 36.9 FHT; start management and can finish Hx & PE
O2 sat: 98
afterwards
Anthropometrics Weight 65kg

- Pre-pregnancy: 65 kg 74kg
- Current (if avail) 74 kg
Height 5’2”
BMI and Classification BMI 26

Obese 1
HEENT
Head:
Eyes:
● Pink palpebral conjunctiva
● Anicteric sclera
Ears:
Nose:
Mouth:
Neck:
● No anterior neck mass
● Thyroid midline and moves with deglutition, Thyroid not enlarged, (-) bruit
● No palpable cervical lymphadenopathy
SKIN/ SUBCUTANEOUS
● No lesions
● No Active dermatoses
PULMONARY
Inspection Symmetrical
No deformities
No use of accessory muscles
Palpation Symmetrical chest expansion, normal tactile fremitus
Percussion Resonant
Auscultation Clear Breath sounds, no wheezing or rhonchi
CARDIOVASCULAR
● Adynamic Precordium
● No murmurs
BREAST EXAM
Inspection ● Unremarkable
● Skin changes e.g. skin retractions and dimpling, discoloration
● Nipple changes e.g. nipple retractions/ visible lesions
Additionals:
- Asymmetry
- Before assuming asymmetry, always ask if it is always have been asymmetrical
- The dominant side usually appear larger than the other side
- Swelling
Palpation ● No masses
○ Size, location, consistency, mobility, tenderness, borders
● No tenderness
● No lymphadenopathies - size, consistency, fixation
○ Axillary LN
○ Regional LN - Supraclavicular, Infra, cervical
● No Discharge
ABDOMINAL EXAM
Ideally, drain the bladder!
Inspection ● Contour: Globular

● With Scars? Ex. C/S scars/Appendectomy scar (surgical scars)
● Fundic height (done in 20-34 wks?): 31 cm
Auscultation ● Normoactive/ Hyperactive/Hypoactive bowel sounds, (-) bruit

● Fetal heart tones (as early as 16 wks and surely at 22 wks): 140 bpm
Palpation ● Leopold’s maneuvers

○ LM1 - fundal grip breech
○ LM2 - Umbilical grip fetal back R/L left
○ LM3 - Pawlick’s grip - presentation cephalic
○ LM4 - pelvic grip - side of cephalic prominence and if engaged or not
● Uterine Contractions:
● Fetal movements:
● Slight on epigastric and RUQ Direct tenderness; if Appendicitis - Rovsings, Psoas,
Obturator sign
● Masses
○ If present, ask for size, consistency, mobility
● Guarding, board like rigidity (signs of peritonitis)
● Hepatomegaly (NV: Liver span 12 cm R MCL)
Percussion Do not percuss pregnant patients
GENITOURINARY
CVA Tenderness none
EXTREMITIES
Pulses, Deformities ● Pulses full and equal = 2+

● No deformities
● Grade 2 bipedal edema
PELVIC EXAM
Inspection and ● External genitalia - Normal

palpation ○ Hair distributed in inverted triangle pattern
(External ○ Inspect the Vulva
Genitalia) ■ No Scars
■ No Erythema
■ No Bleeding
■ No Discharge
○ No gross lesions or masses (rash/ vesicles/ulcerations), episiotomy scar
○ No masses nor tenderness on palpation of perivaginal area
SPECULUM EXAM
Vagina NOT DONE ANYMORE

Erythema, lesions
Vaginal discharge (if present): color, consistency, amount
Notes: high BP. no indication for speculum exam/IE, we can forego with this already (skip whole
pelvic exam until stabilized)
Cervix Cervix is violaceous, everted (anterior or posterior), violaceous, smooth with minimal mucoid
whitish non-foul discharge, no lesions
Others: Cervical ectropion, Ulcers, Masses/ Polyp
INTERNAL EXAM
Cervix ● Cervix soft, long, closed (check dilation if near term)

● No Cervical motion tenderness
If late part of pregnancy:

● Check presenting part and station
● Estimate pelvic capacity and configuration
● Cervical consistency
● Effacement and Dilatation!
○ D-ilatation
○ Effacement
○ P-osition
○ A-mniotic membranes
○ P-resentation
○ S-tation
Uterus Bimanual exam:

Uterus enlarged by how many months, anteverted, non-tender
Adnexa No adnexal mass nor tenderness (cannot be assessed by 12-16 weeks)
RECTAL EXAM (If warranted ex. Endometriosis or presence of mass)

● Tight sphincteric tone
● Smooth rectal mucosa
● No blood on tactating finger
Inspection
• Skin Excoriation
• Rashes
• Hemorrhoids
• Anal Fissure
• Bleeding
• Fistulae
• Abscesses
Palpation
● Lubricate the finger
○ Use the Index Finger
● Insert the finger gently into the anal canal
● Rotate the finger 360 degrees to assess the anal canal
● Palpate for the following:
○ Cervix
○ Size of the Uterus
○ Adnexal area
▪ Ideally, there is nothing to feel or palpate in the adnexal area
▪ Any mass that can be palpated in the area is considered a suspicious abnormality
● Shift to the right side and left side
● Assess the anal sphincter tone
○ Ask the patient to squeeze the finger
● In rectal/rectovaginal exam, you can palpate for tender
nodularities in the uterosacral ligaments (endometriosis).
• Withdraw and inspect finger and assess

○ Blood
○ Stool
○ Mucus
RECTOVAGINAL EXAM
Palpation Palpate the tissue in between the rectum and the vagina (rectouterine pouch of douglas)
- Nodularity
- Tenderness
- Masses
For the rectal finger, palpate the integrity of the rectal mucosa and presence of mass.
- Rectal Mass
SALIENT FEATURES
We have a case of a 36 y/o primigravid, 31-32 wks AOG, married, roman catholic, office worker (work from
home), from Pasig
came in due to chief complaint of: Epigastric pain and Headache 12 hrs prior
History started:
1 Day PTA (last night) patient experienced epigastric pain and headache described as heaviness and
bothersome graded 4/10 → 7/10
For the epigastric pain, patient attributed it to hunger so Ate crackers but to no relief
For headache, patient took paracetamol but afforded no relief
There were no associated nausea, dizziness or vomiting
No other danger signs of pregnancy
1st prenatal 6-7 wks
- CBC (Normal?) Hgb 117 Hct 0.37 WBC 11.9 NEUT 0.78 LYMPHO 0.19 plt 313
- UA Normal
- FBS Normal 82.1 mg/dL
TVS
- Single live IUP, 9 wks 2 days, uterus normal size, normal ovaries
Folic acid
2nd prenatal 9-10 wks transferred to our institution for 4 visits

13-14 wks - unremarkable
- Changed to multivitamins
20-21 wks unremarkable
- Started ferrous sulfate
25-26 wks BP 130/80 (borderline) repeat for 2 hrs after rest
- Advised to monitor BP (not done) - not compliant
- OGTT request - 1 mo after done, normal result
ROS was unremarkable
LMP: Jan. 19-22

PMP: Dec. 25-27
PMH - unremarkable
FH - HPN both parents, DM grandmother
Sexual Hx - coitarche at age ; with total sexual partners
- Last sexual contact 2mo ago
- No contraception
PSH - unremarkable
Objective Findings:
● Normal pelvic exam - external, spec, IE
○ External genitalia:
○ Speculum exam was unremarkable
○ Internal examination was unremarkable
CLINICAL IMPRESSION
Primigravid, pregnancy uterine, 31-32 weeks AOG by LMP or UTZ, presentation, in labor or not in labor, ob/medical
complications, prior deliveries?, other
Impression: Primigravid pregnancy uterine 31-32 weeks AOG, cephalic, Preeclampsia with Severe features
impending eclampsia, Obese Class 1
Prediction of impending eclampsia

§ Persistent occipital and frontal headaches
§ Blurring of vision
§ Photophobia
§ Altered mental status
§ Epigastric or RUQ pain
CNS symptoms!
Severe features of preec: >160/100

● Proteinuria >0.3 g / Serum protein crea ratio >0.3 / Urinary dipstick: 2+ protein
● Serum crea >1.1 g/dL
● Platelet count < 100,000
● Liver transaminases 2x ULN
● New onset of Persistent headache
● Pulmonary edema
● Visual disturbances
TBM:
Mention only the pertinent salient features, and the complications pertaining to preeclampsia
● CNS - blurring of vision, headache
● Renal - Ask about the last urine output, don’t just ask the urinary frequency, urgency, dysuria,
urgency. If AKI secondary to HTN would have a poor urine output
● Liver - epigastric pain & tenderness on deep palpation on RUQ (distention of the Glisson’s capsule)
● No vaginal bleeding & hypogastric pain → absence of complications of HTN - abruptio placenta
● Noncompliant BP monitoring
● BP 160/120
Signs and Headache

Symptoms Epigastric and RUQ pain
Physical BP 160/120 mmHg

examination 65 kg
5’2”
BMI 26 (Obese Class 1)
FH 31 cm
FHR 140 bpm
No uterine contractions
Slight tenderness on epigastric and RUQ = distention of glissons capsule
Grade 2 bipedal edema
Diagnostic/ Urinalysis - to check urine protein

ancillary CBC - to check platelet count
PT/PTT
24 hour urine protein - to check urine protein (>0.3g)
LDH - to check for hemolysis > 600 U/L
Liver enzymes AST/ALT (HELLP) - >2x upper limit of normal r/o HELLP syndrome
Serum crea to check status of kidney (>1.1)
*Repeat labs 2x/week
*75g OGTT at 32 wks - since normal yung last ogtt once stable
RT PCR Swab test - since we will be admitting patient
* If need surgery, dont forget to request for cbc, blood chem, pt/ptt etc. and COVID-19
rt-pcr swab test!
Management Stabilization of BP: CANDICE LEGARDA

● Nicardipine 10 mg in 90 ml NSS at a rate of 10-15 microdrops/min
Titrated at increments or decrements of 5 microdrops/min to maintain BP of
140-150/90-100 (not too low, otherwise an abrupt decrease can lead to
compromised uteroplacental blood flow - decelerations or bradycardia)
● Magnesium sulfate - for seizure prophylaxis in preeclampsia w/ severe features
○ Loading dose: 4g MgsO4 slow IV for 15-20 mins
○ Maintenance dose: MgSO4 1g/hr IV via infusion pump
■ Prepare 10% Calcium gluconate bedside
● 10-20 mL Calcium gluconate IV for 1-5 mins
■ Monitor for:
● Patellar Reflex
● Urine Output (>30mL/hr)
● Respiratory cycles (>12)
○ If doc asks about IM:
■ LD: 4g MgSO4 IV + 5g MgSO4 IM per buttock
■ Every 4 hrs thereafter give 5g MgSO4 one buttock
● Corticosteroids - for fetal lung maturity

○ Betamethasone IM 12 mg every 24 hours for 2 doses
○ Give this cos we never know when she will need emergency abdominal
delivery
○ It’s ok if it’s just 1 dose completed; should not be a limiting factor that can
hinder emergency abdominal delivery
ADMITTING ORDER:
● Admit px
● Diet NPO (since we are not sure if there will be an emergency delivery)
● Insert IV access and Urine Catheter (for MgSO4 monitoring- mgso4 toxicity may
present as oliguria)
● Stabilize BP (mentioned above)
● Monitor BP every 15 minutes
● Monitor urine output every hour
● Monitor Fetal heart rate every 30 mins
● Monitor for uterine contractions
If BP becomes controlled:
● Daily fetal movement/kick counting
● Biometry every 2-4 weeks
● BPS weekly w/ or w/o Doppler
● Repeat lab tests (AST, ALT, etc) - at least 2x/week
Deliver: at 34 weeks (since preec with severe features)

● If BP is controlled = Can do labor induction; ideally: 34 wks AOG
● If with HELLP (according to lab results), warrants termination of pregnancy at this
time
● If BP is not controlled = deliver now; below
Mode of delivery: (can do IE to check for cervical dilatation once patient is stabilized)
● Vaginal delivery with forceps
○ Minimum station +2
○ To shorten the 2nd stage of labor
● CS
○ if unfavorable (bishop score <4; 1cm dilated only)
○ Fetal growth restriction
○ Oligohydramnios
○ Nonreassuring fetal pattern
Anesthesia of Choice:
● Epidural anesthesia
○ As it has effects on lowering BP, with adequate anesthesia, for pain &
relaxed pelvic floor muscles
Patient has Risk Factors for Preeclampsia:

● Age
● Family Hx
● Primparity
● Obesity
So advice prophylaxis for pre-eclampsia especially if presents with risk factors:

● Aspirin 150 mg low dose (start within 12-16 weeks)
● Elemental calcium 1.5g-2.0 g per day (2 tablets a day)
* TBM Notes:
- Epidural anesthesia preferred for vaginal delivery- assists in controlling BP
- Biomarkers for preeclampsia: (ideally, but not all labs have it and it is EXPENSIVE)
- Antiangiogenic biomarkers
- sFlt-1 (Soluble FMS-like tyrosine kinase-1 receptor)
- PIGF (Placental growth factor)
- Activin & Inhibin A
- PAPP-A
- sEndoglin
- Uterine artery doppler velocimetry (before 20 weeks or mid pregnancy)
- BP Monitoring - closer followup
- Due to risk of preeclampsia after 12 wks AOG, can start aspirin; calcium
1500-2000mg recommended per day to also reduce risk of preeclampsia
- Recognize if this is an emergent case, can skip part of taking entire history and
start with initial management
- Impending eclampsia - since there is CNS symptoms in this case
- After mgso4 and steroids, sched already for CS
Differentials
Signs and
Symptoms
Physical
examination
Reason for R/O

Diagnostic/
ancillary
Management
EXTRA NOTES:
DIAGNOSTICS/ ANCILLARIES (ROUTINE IN BOLD)
Ultrasound To determine the fetal viability and confirm location if intrauterine pregnancy (r/o
ectopic pregnancy which is extrauterine, especially if patient is irregular
menstruation or irregular menses
TVS: <12 weeks,
*if confirm mo na napregnant sya, no need for immediate ultrasound
Transabdominal UTZ: if>12 weeks, fetal biometry din ata tawag sa transabdominal
UTZ. measure the crown rump length, AOG and fetal aging
BPS done starting 28 weeks to assess fetal well being

(amniotic fluid index, fetal tone, fetal movement, fetal breathing and fetal heart
rate)
FBS +/- Lipid profile If high risk 75 oGTT agad: fbs 92, (1)180, (2) 153
If non high risk FBS muna if <92 normal then go back ng 24-28 weeks then if
normal go back ng 32 weeks
If 92-126 GDM
If >126 overt DM
*note if GDM =38 weeks deliver-41 weeks

Tx:
1. diabetic diet (Normal:30-35 kcal/kg, obese 24 kcal/kg/day)
Caloric composition: carbs 55%,protein20%, fats 25%
2. Refer to Dietary service
3. 1 pt CBG monitoring
4. Refer to endo and fetal surveillance
5. 2nd trimester: do sonographic imaging for congenital anomalies
6. 3rd trimester fetal surveillance
7. You can give insulin pero aralin ko nalnag
Urinalysis UTI and renal function

Culture for asymptomatic bacteriuria
CBC + PLT 1st trimester=11

2nd=10.5
3rd=11
To know the hematologic status and physiologic anemia
For leukocytosis if may infection
ABO XT BT Determine ABO, RH status for hemolytic transfusion
Serology Hbsag:
Determine Hep B status, for possible intervention
* Use double glove delivery
* Give the neonate Ig & HepB vaccine immediately after delivery if reactive!
Ideally done on 1st trimester, repeated on the 3rd
* Can be done in the 3rd trimester for cost-effectiveness * Greatest transmission is during
the 3rd trimester
Syphilis
Done near term (3rd trimester)
Detect previous or current infection of syphilis
Non-treponemal (nonspecific) screening tests
● * VDRL (Venereal Disease Research Laboratory)
● * RPR (Rapid Plasma Reagin)
§ If positive, do treponemal (specific) confirmatory tests
● * FTA-ABS (Fluorescent Treponemal Antibody Absorption)
● * TP-MHA (Treponema Pallidum Microhemagglutination Assay)
HIV
Pap smear This is not usually done except if s/s of cervical cancer or foul smelling vaginal
discharge or post coital bleeding
For gyne
KOH smear
Coagulation studies
Iron studies
Thyroid function tests TSH, FT4, FT3
Extra Notes Prenatal work ups: (Initial visit)

● CBC with platelet count
● Urinalysis
● Blood typing
● Urine culture - if may signs of bacteriuria (since gold standard)
● FBS - always request for this since philippines
● HBsAg (sa 3rd trimester na)
● For STDs
○ VDRL/ RPR
○ HIV Elisa
● Pap smear
1ST TRIMESTER
● Request an early ultrasound for location of pregnancy, proper AOG, fetal
viability
Congenital anomaly scan if high risk - 15-20 wks for neural tube defects
AT 24-28 wks AOG
● 75g OGTT
● Biometry + BPS
Note: Always request for repeat CBC to check if may anemia lalo na if nearing
term
MANAGEMENT
1st Trimester Prenatal Vitamins

● Folic acid 0.4 to 0.8 mg (400 mcg) per day one month before conception to first
trimester (If with hx of NTD give 4mg/day instead)
● Drink 1-2 glass of milk per day OR Calcium 100mg per day (if no nausea and
vomiting)
Additional:
● Caloric intake should be 100-300 kcal per day
● Add protein to diet (egg)
2nd Trimester Prenatal Vitamins

● Multivitamin 1 tab per day (vitamin D and zinc)
● Iron (Ferrous sulfate 30 mg/day)
○ 27 mg elemental iron/day 30 mins premeal
○ Only give after 1st trimester d/t GI irritation
Prevention ● No alcohol, smoking, illicit drug use and caffeine <3 cups of 300mg/day
(Education) ● Advise vaccinations - Tdap 27 and 36 wks AOG, Flu vaccine at any AOG
○ If no vaccines: Flu and DPT (3 dose starting 2nd trimester 1 month apart last
dose postpartum)
● Stress importance of taking supplements and coming in for regular check up
● Educate patient of 10 danger signs and consult immediately once experienced
● If placenta previa - bed rest; avoid strenuous activity, coitus
● Stop smoking, drinking
Complications ● Nausea and vomiting of pregnancy - small frequent feeding, antiemetics

and Other ● If pre-eclampsia - give aspirin 150mg at 12 wks AOG if high risk
diseases ● If with heartburn = PPI
● If asthma
○ Avoid triggers
○ Adherence to medications SABA etc
● If GDM
○ Diet and exercise - diabetic diet
○ Daily CBG monitoring
Follow up All OB cases require follow up:

● <28 wks - monthly
● 28-36 wks - every 2 weeks
● >36 wks - every week
Additional Notes:
Signs of pregnancy:
Presumptive evidences:
● Nausea (Morning sickness)
● Vomiting (Hyperemesis gravidarum)
● Urinary symptoms - urinary frequency, UTI
● Fatigue
● Quickening - perception of fetal movement 16-18 in primi; 18-20 in multi
● Breast tenderness/ engorgement
● Amenorrhea >10 days of expected mens
● Skin pigmentation - striae, linea nigra
Probable
● Abdominal enlargement
● Cervical changes - soft, violaceous
● Braxton hicks contraction
● Ballottement
● Preg test
Positive
● FHT
● Fetal movement perception by examiner
● Ultrasound
Gold standard for diagnosis of IUGR is ultrasound biometry.. This is to assess the size of the fetus and amount
of amniotic fluid...it should also be classified as asymmetric or symmetric..
HXPE-Jimenez, Jaen SALIENTDDX-Intia, Inovejas MANAGE-Jose, Inumerable + Jardiolin
Script here.
NAME marlyn dee AGE: 22 DATE: August 2_, 2021
BIRTHPLACE: quezon city CIVIL STATUS: Married # OF YEARS RELIGION: Catholic

ADDRESS: quezon city MARRIED: 2 years
OCCUPATION: accountant EDUCATION: college graduate NATIONALITY: filipino

accounting
CC: tumataas blood pressure 140/90

● ONSET: 2 weeks ago
● LOCATION:
● DURATION:
● AGGRAVATING
● ASSOCIATED: No headache, no blurring of vision, no convulsions, no difficulty breathing
● RELIEVING: No medications, rest but did not relieve
● TEMPORAL: every time bp is checked
● SEVERITY: 140/90
● PREGNANCY TEST: none
Usual bp: 110/80

2wks ago started to increase: 140/90
No labs no ultrasound since telemedicine

Prenatal Consult: 2 times
- April & (multivitamins, ferrous sulfate) -
Teleconsult, no lab requests
ASSOCIATED SYMPTOMS: ALWAYS CHECK FOR DANGER SIGNS OF PREGNANCY!

1. HEADACHE (-)
SYMPTOM 1 2. BLURRING OF VISION (-)
● ONSET: 3. PROLONGED VOMITING (-)
● LOCATION: 4. FEVER (-)
● DURATION: 5. NONDEPENDENT EDEMA (-)
● CHARACTERISTICS: 6. HYPOGASTRIC PAIN (-)
● AGGRAVATING 7. DECREASED FETAL MOVEMENT (-)
● ASSOCIATED: 8. DYSURIA (-)
● RELIEVING 9. BLOODY VAGINAL DISCHARGE
● TEMPORAL 10. WATERY VAGINAL DISCHARGE
● SEVERITY
OBSTETRIC TOTAL PAST PREGNANCY: 0 FULL TERM: PREMATURE: 0 ABORTION: 0 ALIVE: 0 OB SCORE:
HISTORY G1P0 (0-0-0-0) 0
G1P0
1.
NOTES:
2.
NOTES:
3.
NOTES:

MENARCHE 9 years old COITARCHE 20 years old
INTERVAL 9 years old: Irregular (every 3 months or 4 months) NO. OF SEXUAL 1

PARTNERS
15 year old to pre pregnancy: regular
POST-COITAL (-)
DURATION 3-4 days BLEEDING
AMOUNT 3-4 regular pads per day moderately soaked DYSPAREUNIA
SYMPTOMS none CONTRACEPTIVES

USE
OCCUPATION OF
LMP Feb 28, 2021 HUSBAND
PMP
AOG 25-26 weeks AOG ● none
EDC November 7, 2021 GYNECOLOGIC HISTORY (if needed):

●
Please show solution here:
AOG:
LMP: February 28
31+30+31+30+31+26 =
AOG: 25 - 26 weeks AOG
EDC
Feb 28, 2021 (2 months) + 9 months = 11 months (November)
28 days + 7 days = 7th day
EDC = November 7, 2021

SURGERIES, none DM father
TRANSFUSION
HPN father
OB & GYN none
PROCEDURES CANCER Mother: leukemia
HOSPITALIZATION none Others:
IMMUNIZATION (+) covid vaccine

(Childhood, Hepa B,
Covid)
COMORBIDS (-) HTN (-) asthma (-) DM
MEDICATIONS No medications
ALLERGIES Banana and lanzones
SOCIAL HISTORY PREVIOUS PRENATAL CHECKUP -- all telemed

SMOKING no WHO
ALCOHOL Occasional, did not drink starting pregnancy WHERE
COFFEE WHEN
DRUGS no FREQUENCY 2 times previously
DIET RESULTS None due to teleconsult
EXERCISE Pre pregnancy (+), now (-) MEDICATIONS Multivitamins, Ferrous Sulfate
REVIEW OF SYSTEMS:
GENERAL No fever
No bleeding
SKIN, HAIR, NAILS No watery discharge
EYE
EAR
NOSE
MOUTH
CARDIO
PULMO
GASTROINTESTINAL
GENITOURINARY
HEMATOLOGY
NEUROLOGIC
ENDOCRINE
MUSCULOSKELETAL

● GENERAL SURVEY ● PELVIC
○ MENTAL STATUS: AMBULATORY, NOT IN DISTRESS, conscious, ○ INSPECTION OF EXTERNAL GENITALIA
coherent ■ No lesions scars or erythema,mno bleeding and discharge,
○ BODY HABITUS: no masses and ulcerations
○ WEIGHT: 160lbs = 72.72kg ○ SPECULUM EXAM character of discharge
○ HEIGHT: 5 2” = 1.56m ■ Cervix is violaceous with mucoid discharge
● VITALS SIGN: ■ Foul-smelling discharge
○ BP:140/100 ● Creamy, non-adherent to the walls
○ HR: 99
○ RR: 20
○ INTERNAL EXAM
○ TEMP: 35.7
● ANTHROPOMETRIC DATA ■ CERVIX - long, soft, closed
○ HEIGHT: ■ UTERUS -
○ WEIGHT: pre-preg , preg 160lbs ■ ADNEXA no need to ask adnexa tenderness cos cannot
○ BMI: 29.5 Obese Class 1 assess anymore w/ 3months AOG
● SKIN, HAIR, NAILS: ■ CUL-DE-SAC
● HEENT: ■ BISHOP’S SCORE:
○ INSPECT: pink palpebral conjunctiva, anicteric sclerae, no nasal
● Dilatation:
discharge, no lesion on mouth, no mass in neck, midline thyroid,
thyroid not enlarged ● Effacement:
○ PALPATE: ● Consistency:
○ PERCUSS: ● Position:
○ AUSCULTATE: ● Station:
● CARDIO: ■ CLINICAL PELVIMETRY
○ INSPECT:adynamic precordium, 5th LICS midclavicular ● RECTAL EXAM
○ PALPATE: no heaves, lifts, thrills, ○ INSPECT:
○ AUSCULTATE: no murmurs ○ PALPATE:
● RESPIRATORY:
● RECTOVAGINAL EXAM
○ INSPECT:
○ PALPATE:
○ PALPATE:
○ PERCUSS:
○ AUSCULTATE:
● BREAST:
○ INSPECT: no asymmetry, no masses, no swelling tenderness
dischargeglob
○ PALPATE:
○ PERCUSS:
○ AUSCULTATE:
● ABDOMINAL dont forget to ask FHT, Fundic height
○ INSPECT: globular, (+) striae
○ AUSCULTATE: fetal heart tones: 140bpm, normoactive bowel
sounds
○ PERCUSS (DONT PERCUSS PREGNANT)
○ PALPATE: mass - midline;
Fundic height - 26cm
● EXTREMITIES
SALIENT FEATURES
Script: We are presented with a 22 year old, GXPX(XXXX), who comes in with a ______ of ___ duration, accompanied by_____, and positive?pregnancy test. On PE,
pertinent PE would include ______. On speculum exam, the cervix was _______.
22 yrs old - No headache

LMP: February 28 - No blurring of vision
25-26 weeks aog by LMP and - No HTN pre pregnancy
CC: High BP - No edema
Usual bp: 110/80 - no convulsions,
2wks ago started to increase: 140/90 - no difficulty breathing
(PE) Current BP: 140/100 - No danger signs of pregnancy
Not relieved by rest
Primigravid
Obese class 1 (℅ Asia Pacific)

BMI: 29.5
Family history of HTN and DM
Creamy, violaceous foul smelling discharge
TENTATIVE DIAGNOSIS/ FINAL DIAGNOSIS: G1P0 Primigravid, Pregnancy uterine, 25-26 weeks AOG by LMP, Gestational Hypertension to r/o Preeclampsia, Obese
Class 1, Mixed Vaginosis?
DIFFERENTIALS RULE IN RULE OUT
1. Gestational HTN ● After 20 weeks ● Won't be able to rule out completely until iBP
○ AOG: 25 - 26 weeks AOG lowers? >12wks postpartum ??
● 2wks ago started to increase: 140/90
● Current: BP:140/100
● HTN w/o proteinuria OR other signs and
symptoms of preeclampsia-related end organ
dysfunction after 20 wks
●
1. Preeclampsia ● After 20 weeks ● No headache

○ AOG: 25 - 26 weeks AOG ● No blurring of vision
● 2wks ago started to increase: 140/90 ● No edema
● Current: BP:140/100 ● Risk factor: (-) DM, (-) HTN
● Primiparity ●
● Family hx of HTN (father)
********
● BMI: 29.5 Obese 1 (pregnant wt) ito tho
2. Chronic hypertension ● 2wks ago started to increase: 140/90 (23-24 ● Before 20th week AOG - persists 12 weeks
weeks) postpartum
● Current: BP:140/100 ● Usual BP: 110/80
● No hx of HTN
○ Hypertension w systolic BP
>140mmhg and/or diastolic BP
>90mmhg occurring before pregnancy
or before the 20th week AOG and
persists after 12 weeks postpartum

24 hour urine protein OR urinalysis OR protein/creatinine ratio If Gestational HTN and r/o Preec with severe: Manage as outpatient
● Check for proteinuria
● 24HR: >300 mg PNCU: Since no labs were requested in previous PNCU
● UA: +2 ● CBC
● P/C: >0.3mg ● Urinalysis
● Blood typing and Rh
If no proteinuria, request for the following to check RENAL FX: ● FBS
● Serum creatinine: >1.1 mg/dl or 2x increase baseline
● Transaminases: >60 or 2x increase baseline Prescription since <34 weeks (expectant management)
● BP control: Methyldopa 250 mg q6 PO
Investigate for HELLP Syndrome ○ Not sure pero target BP control to usual BP: <120/80?
● LDH >600 ○ BP monitoring: 2x/day
● Transaminase >60 or 2x ULN ● Prophylaxis for preeclampsia:
● PLT <100 000 ○ Low dose aspirin 150 mg/tab PO OD
● Hemoconcentration - hallmark (if asked) ■ stop at 36 weeks
○ Check for hematocrit (should be increased) ○ Calcium 1g/day PO
● Mixed vaginosis - combined tx ba to
Fetal Assessment hook to EFM ○ Miconazole + Metronidazole ba?????
● Transabdominal UTZ - ascertain location, viability, number of fetuses ■ Insert 1 suppository intravaginally ODHS x 7 days
● Fetal movement counting
● NST
● BPS - prioritized before administration of medications Only if (+) with severe features in labs
○ 8/8 ● BP control: Nifedipine 10-20 mg every 20 minutes
○ fetal tone, breathing, movement, AFI, NST - modified BPS ○ Target BP: <140-155/<90-105
○ If normal ung first 4, no need to do NST
● Biometry - to check if appropriate for gestational age and to check if there’s
IUGR Prenatal Supplements:
● Umbilical artery doppler(uterine artery doppler muna to predict ● Ferrous sulfate 325 mg/tab OD 30 minutes before meal
preeclampsia? ● Multivitamins 1 tab OD
Follow up
● NST/BPS - twice weekly
● Biometry - every three weeks
● Fetal kick counts - daily
ADMITTING ORDER - Admit Diet Monitor Investigation/Intervention Therapeutics
ADMIT
DIAGNOSIS
CONDITION
VITALS
ACTIVITY
NURSING ORDER
DIET
IV FLUIDS
MEDICATIONS
LABS
CALL HO
Notes for cares:

- Avoid asking irrelevant questions just for the sake of completion. Doc agreed that it is ok for completion but focus first on the CC.
- Should be systematic when asking for history
- Ask first about CC before going to other history
- Don't ask redundant questions. Take note of the patient’s answer para di maulit question, don’t stick to the template
- Unsure if what area of the history is being asked - HPI or History already
- Ask relevant questions only because sometimes, it may be offensive to the patient (such as # of sexual partners, it may come off as the patient being
polygamous)
- [RMG] No need to ask about the mental status of the patient. Just state that the pt is conscious, coherent and not in respiratory distress! Just ask if the
patient is ambulatory since you won’t know
- Know how to perform the pe. For example, how to elicit heaves, lifts, and thrills
- Hypertrophy- heaves (base of the hand, ulnar aspect)
- Time management for history and pe, wasn’t able to discuss differentials, ancillaries and management because history because of time restraint
- No need to ask already established information (uterus: normal sized, anteverted bc px AOG 25wks)
- Pre pregnancy weight should be asked - to know if patient is really obese or if weight is just because of the growing fetus
- Nothing was really asked with regards to hypertension, should expound further to assess situation of the patient
- 2 weeks ago
- May ginawa ba? Nagpahinga daw
- No questions relevant to CC:
- Examples:
- if nung nagpahinga, nag normalize ba?
- What position? Flat on bed? Left lateral?
- Nagimprove ba sa supine position or lateral position?
- Buong araw ba hypertensive, kinuha mo ba bp mo after magpahinga?
- How to get the 24 hr urine collection
-
NAME: anghelita reyes AGE: 30 BIRTHDATE: DATE: August 23, 2021
ADDRESS: Manila SEX: F CIVIL STATUS: # OF YEARS RELIGION: Catholic

Married MARRIED:
OCCUPATION: Nurse EDUCATION: NATIONALITY: Filipino
CC: vaginal bleeding

● ONSET: Day of consult
● LOCATION:
● DURATION:
● AGGRAVATING
● ASSOCIATED: Pelvic & abdominal pain, Headache (early morning)
● RELIEVING
● TEMPORAL
● SEVERITY: Headache 5/10
SYMPTOM 1:
● Vaginal bleeding (this morning)
● Fully soaked
SYMPTOM 2:
● Temporal Headache “nakadagan”, 5/10
● 5:00am
● No meds taken, BP was not taken also
SYMPTOM 3:
● Abdominal pain “parang naglalabor”
● Midline
Last pncu
24hr urine protein: Inc

Prescribed with Methyldopa
Floaters seen
No N&V
OBSTETRIC TOTAL PAST PREGNANCY: 2nd FULL TERM: PREMATURE: ABORTION: ALIVE: OB SCORE:
HISTORY pregnancy na ata to?
1. G1 2019 6.8lbs girl NSD No complications, no Increased BP

before
NOTES:
2.
NOTES:
3.
NOTES:

MENARCHE COITARCHE
INTERVAL regular NO. OF SEXUAL

PARTNERS
DURATION 6 days
POST-COITAL
AMOUNT 2-3 pads 1st days soaked regular pads BLEEDING
SYMPTOMS none DYSPAREUNIA
CONTRACEPTIVES
USE
LMP January 1-6
PMP
AOG
EDC

SURGERIES, DM
TRANSFUSION
HPN
OB & GYN
PROCEDURES CANCER
Others:
HOSPITALIZATION
IMMUNIZATION
COMORBIDS
MEDICATIONS Methyldopa 250mg tab BID - 2 months already
SOCIAL HISTORY ALWAYS CHECK FOR DANGER SIGNS OF PREGNANCY!

1. HEADACHE (+)
SMOKING No
2. BLURRING OF VISION
ALCOHOL 3. PROLONGED VOMITING
4. FEVER
COFFEE 5. NONDEPENDENT EDEMA
6. EPIGASTRIC/RUQ PAIN
DRUGS 7. DECREASED FETAL MOVEMENT
8. DYSURIA
DIET Fish & chicken 9. BLOODY VAGINAL DISCHARGE
10. WATERY VAGINAL DISCHARGE
EXERCISE Not often
REVIEW OF SYSTEMS:
GENERAL No cough, colds

No dyspnea, easy fatigability
SKIN, HAIR, NAILS
EYE
EAR
NOSE
MOUTH
CARDIO
PULMO
GASTROINTESTINAL
GENITOURINARY
HEMATOLOGY
NEUROLOGIC
ENDOCRINE
MUSCULOSKELETAL
FOCUSED PHYSICAL EXAM:

● GENERAL SURVEY ● EXTREMITIES- No Edema, Full and equal, (+2) DTRs
○ MENTAL STATUS: Wheelchair-borne NOT IN DISTRESS ● PELVIC
○ BODY HABITUS: ○ INSPECT THE VULVA (EXTERNAL GENITALIA)
○ WEIGHT: ■ SCARS- Median episiotomy
○ HEIGHT:5’3 ■ ERYTHEMA
● VITALS SIGN: ■ BLEEDING - blood coming out of introitus
○ BP:160/100 ■ DISCHARGE
○ HR: 90 bpm ■ MASSES
○ RR:
■ RASH/ VESICLES/ ULCERATIONS
○ TEMP: 36.5
● ANTHROPOMETRIC DATA ■ PUBIC HAIR DISTRIBUTION
○ HEIGHT: 5’3 ○ SPECULUM EXAM (INSPECT THE CERVIX)
○ WEIGHT: 45kg (pre pregnancy) → 52kg ■ SMOOTH, VIOLACEOUS
○ BMI: 17.5 pre, 20.3 preg ■ DISCHARGE - cervix covered by blood
● EYES: ■ CERVICAL ECTROPION
○ PALPEBRAL CONJUNCTIVA- PINK, ANICTERIC ■ ULCERS
● CARDIO:
■ MASSES/POLYP
○ ADYNAMIC PRECORDIUM, (-) HEAVES, LIFTS, THRILLS
○ SLIGHTLY TACHYCARDIC ○ INTERNAL EXAM
● RESPIRATORY: ■ CERVIX 1cm dilated
○ SYMMETRICAL EXPANSION,NO LAGGING, NO WHEEZES ■ UTERUS enlarged to AOG, movable, tender, hard
● BREAST: ■ ADNEXA masses, tenderness
○ INSPECTION: ■ CUL-DE-SAC bulging or deep fornices
■ ASYMMETRY ■ BISHOP’S SCORE
■ SWELLING ● Dilatation:
■ MASSES ● Effacement:
■ SKIN CHANGES ● Consistency:
■ NIPPLE CHANGES ● Position:
○ PALPATION: ● Station:
■ ASYMMETRY ■ CLINICAL PELVIMETRY
■ SWELLING ● INLET: true, obstetric, diagonal conjugate
■ MASSES ● MIDPELVIS: ischial spine not prominent, curved
■ EXAMINE AXILLARY LYMPH NODES sacrum, walls divergent
● SIZE ● OUTLET: wide pubic arch, fist can fit the bituberous
● CONSISTENCY diameter
● FIXATION
■ EXAMINE REGIONAL LYMPH NODES
● INFRACLAVICULAR ● RECTAL EXAM
● SUPRACLAVICULAR ○ INSPECTION
● CERVICAL ■ SKIN EXCORIATION
● ABDOMINAL (ASK PX TO VOID FIRST) ■ RASHES
○ INSPECTION ■ HEMORRHOIDS
■ globular, moderate striae, scars ■ ANAL FISSURE
■ BLEEDING
■ FH 32cm FISTULAE
■
■ Strong contractions ABSCESSES
■
■ FEMALE ESCUTCHEON ○ PALPATION
○ AUSCULTATION ● RECTOVAGINAL EXAM
■ NORMOACTIVE BOWEL SOUNDS ○ PALPATION
■ FHT: 140bpm on L side after brief resolution of contraction ■ NODULARITY
○ PALPATION: ■ TENDERNESS
■ Direct and rebound tenderness ■ MASSES
■ FUNDIC HEIGHT(18weeks)
■ LEOPOLDS (28weeks) - cannot be done due to contractions
OTHER PHYSICAL EXAM:

● SKIN, HAIR, NAILS: This is a case of 30 years old G2P1 (1001) w/ chief complaint of
● HEENT: Vaginal Bleeding
● GI:
● GU:
● MSK:
● NEUROLOGIC: PERTINENT POSITIVE PERTINENT NEGATIVE
● 30 y/o G2P1 (1001) ● 2nd prenatal: normal

Breech presentation - FHT above umbilicus ● LMP: Jan 1- 6 (33-34 weeks ○ CBC
AOG) ○ UA
*FHT above umbilicus: breech ● Profuse Vaginal bleeding this ○ FBS
FHT below umbilicus: cephalic morning ○ Folic Acid
● (+) abdominal pain ○ Iron supplements
● (+) Mabigat 5/10 frontal ● No nausea vomiting
headache ● No fever
● On methyldopa (20 months) ● No edema
● Painful crampy epigastric ● No dysuria
(gitna) abdominal pain ● No DOB, easy fatigability
(labor-like) ● Normal HEENT
● 25 weeks AOG ● Normal Lungs
○ BP: 140/90 ● Normal Breast
○ 24hr urine protein: ● Slightly tachycardic
high ● Normal extremities
● (+) Floaters
● Wheelchair borne, in pain
● 160/100mmhg
● HR 90bpm
● 36.5
● RR?
● Abdomen
○ FH 32cm
○ Strong contractions
○ FHR: 140 bpm
○ Tender on palpation
○ LM can’t be done
● Pelvic Exam
○ Median Episiotomy
scar
○ Blood clots on
introitus
○ Cervix covered by
blood
○ Cervix 1 cm dilated
○ Uterus compatible
with AOG
○
TENTATIVE DIAGNOSIS/ FINAL DIAGNOSIS: G2P1 (1001), pregnancy uterine, 33-34 weeks AOG, Abruptio Placenta, Preeclampsia with severe features
Pt. is 30 y.o G2 P1 with a chief complaint of vaginal bleeding

(+) Abdominal pain
(+) Headache
(+) Wheelchair borne, with pain
(+) Cervix 1 cm dilated
BP: 140/90
24 hr Urine Protein: High
1. Pre-ecclampsia with severe features (+) On methyldopa 250 mg BID

140/90 bp
24hr urine protein: proteinuria
Headache
Visual symptoms: Floaters (eye)
2. Abruptio placenta Vaginal bleeding (2nd half of pregnancy)

Sudden onset Abdominal pain
Pt. has htn 140/90 and taking methyldopa
Tetanic contractions
Uterus hard, tender
3. Placenta previa Vaginal bleeding in the 2nd half of pregnancy Vaginal bleeding should be painless
No abnormal findings in TVS (location of placenta)
Painless bleeding
4. Preterm labor Regular contractions No Watery discharge

Contractions are tetanic

● ULTRASOUND (if suspecting placenta previa, ) Hook to EFM - to check for fetal status (check if there is fetal compromise
● CBC+PLT particularly late decel = uteroplacental insuff)
● Blood typing ABO CROSSMATCH
● COAGULATION STUDIES Management of Abruptio:
● RT-PCR ● Place 2 large bore IV access
● Clotting time, Bleeding time, ● Prompt and intensive intravascular resuscitation with blood and
● Best way to assess DIC (Cost effective): crystalloid
○ Clot observation Test- Bedside ● Emergency CS
○ Put drop of blood in test tube and observe until a clot forms ● In case of fetal death, vaginal delivery is preferred
● D-dimer - To check if may DIC (Expensive) ● No need to give steroids since emergency CS na
Management of Pre-eclampsia:
● Nicardipine IV:
JZM Notes: ○ D5W 90mL + Nicardipine 10mg/hr in soluset, start drip at 1
- Can deduce presentation based on auscultation of FHT mg/hr
- FHT above umbilicus: breech
- FHT below umbilicus: cephalic Magnesium sulfate - prevent seizures, neuroprotection
- Still do the other PE, pero mention na “I think this is abruptio so I will - IM Per gluteal/buttocks
focus on abdominal” then quick pasada for other PE - Loading dose: 5g per buttocks if IM, 4g slow IV push if intravenous
- If thinking na previa “Doc i will not do IE because I’m thinking this is a - Every 6 hours until delivery
previa case”
- “I would like to ask for sexual hx etc but since this is an emergency, I Delivery
will skip” - CS
- Basta Rationalize - Timing: if controlled BP can extend up to minimum of 34 weeks
- UTZ to check for previa at 28-32 weeks - Additional management while waiting for the actual delivery before 34
- Adnexa not palpable >12wks AOG - (JZM) weeks:
- Continue antenatal fetal surveillance
- BPS
- Watch out for uteroplacental insufficiency:
oligohydramnios
- Indication to deliver even if not 34 weeks
- Emergency cs if not controlled
ADMITTING ORDER - Admit Diet Monitor ADMITTING ORDER SAMPLE - Admit Diet Monitor
Investigation/Intervention Therapeutics Investigation/Intervention Therapeutics
ADMIT Admit to delivery room? Labor room? ADMIT Admit to (OB ward, surgical ward, OR)
DIAGNOSIS G2P1, pregnancy uterine, 33-34 weeks AOG, DIAGNOSIS Diagnosis
Abruptio Placenta, Preeclampsia with severe
features CONDITION Serious, guarded, critical, stable, etc
CONDITION VITALS Check vitals every 15 mins, etc
VITALS Check vital signs every 15 minutes ACTIVITY Bed rest, bed rest w/ bathroom privileges, crib
ACTIVITY
and mother’s arms, ad lib (at one’s pleasure),
Bed rest
no restrictions, etc
NURSING ORDER
NURSING ORDER For nurses to routinely do
DIET NPO DIET NPO, 1000 calorie, no salt, special diets, etc
IV FLUIDS Plain NSS 100ml/hr IV FLUIDS Ex. D5 .2 NS + 20 mEq/L of KCL to run at 14
MEDICATIONS ● MgSO4 cc/hr
○ Loading dose: 4g slow IV in 100mL
saline solution MEDICATIONS Medications should include name, dose, route
○ Maintenance 1g/hr and frequency. Oxygen is included here.
● Nicardipine IV:
○ D5W 90mL + Nicardipine 10mg/hr in
soluset, start drip at 1 mg/hr
Ex. Nifedipine 20 mg/tab 1 tab daily PO
LABS LABS
LABS ● CBC
● Blood typing ABO CROSSMATCH CALL HO Red flags or warning signs
● COAGULATION STUDIES
● D-dimer (expensive) Ex. if HR <60 bpm
CALL HO
General Data
ACT: Introduce that your part of the medical team, like “kasama po ako ng residente…” (to build rapport!)
Name: RB? Age: 22 Birthday: Address:
Civil Status: Married # Years married: Nationality:
Education: Occupation: None at the moment Religion: Catholic
Chief Complaint: Masakit ang pag-ihi Comments/Suggestions
HPI
If Pregnant/suspicious of preg: Onset: 1 day ago Danger signs

Location:
● Presumptive symptoms Duration: Paano nyo po idedescribe
○ Morning sickness (6-18) Character: ung sakit??
○ Idiosyncrasies of taste and Associated: No bleeding, No passage of stones, no back pain, warm to touch,
smell
○ Fatigue urinary frequency, no nausea & vomiting AOG? Stat if ever 12-13
○ Urinary frequency, nocturia (1st weeks AOG siya ty :)
& 3rd trimester)
○ Amenorrhea
Takes buko juice Vaginal discharge kaya?
○ Skin changes Sa PE nalang siguro
○ Increased temp (6) reinforce ayaw niya
○ Quickening (P-18-20; M-16-18) bumabalik eh
● Probable signs
○ Abdominal enlargement (12)
○ Braxton Hicks (28) CARES: Forgot to ask
when masakit pag umiihi
1. Headache
4. Fever and chill
periorbital)
7. Hypogastric pain
8. Dysuria

● Onset
● Location
● Duration
● Character
● Assoc/Aggrav
● Allev
● Rad
● Tempo/Timing
● Severity
● Where
● When last ff
● How many
● Weight gain
● Assessment
● Labs & Results
fetus, placenta
LMP: June 1-4, 2021 Comments/Suggestions

PMP: May 2021
AOG (if ever): 12 weeks 1 day
MIDAS Menarche
If TERM preg: focused hx Interval Regular
na (“Your patient has big
3 days
Amount
tummy, who cares of Symptoms
menarche”)
OB Hx G: 0 P: 0 TPAL:
If Pregnant AOG: 12 Weeks 1 Day EDC: March 8, 2022
Sexual hx Coitarche
# of Partners
Job of partners
Last sexual contact
Post Coital bleed
Dyspareunia
Family Planning
Past Medical hx Comorbids (HTN/DM/Thyroid) No comorbids

Medications No meds
Surgeries No surgeries
Transfusions No transfusions
Hospitalizations Unrecalled immunization status; covid vaccine (1 dose, yesterday);
Immunizations
Prev Prenatal Check up
Personal & Social hx Smoking Non-smoker

Alcohol Non-alcohol drinker
Drugs No intake of illicit drugs
Diet Diet: Rice
Exercise Exercise: None
Family hx DM (-)
HTN (-)
Cancer (-)
Asthma (-)
Thyroid disease
Blood dyscrasia
Seizure
Heart disease
General (-) Weight Changes, (-) Changes in appetite, () Fever, () Chills, (-) Sleep Changes, CARES: “Easy fatigability”
HEENT (-) Headache, (-) Blurring of Vision, () Exophthalmos and “Review of Systems”
Cardio (-) Palpitations, (-) Easy fatigability Don’t ask what you will
Pulmo (-) Cough, (-) Colds, () Dyspnea, () Chest pain
appreciate in PE.
Melena
Endocrine () Polydipsia, () Polyuria, () Polyphagia, () Heat intolerance, () Cold intolerance, () Irritability
Prenatal Check up)
1. Headache
4. Fever and chill
5. Nondependent
Edema (hands,
periorbital)
7. Hypogastric pain
8. Dysuria
9. Water vaginal
discharge
10. Bloody vaginal
discharge

TCL: State PE in this way always: “I will check for…”
TCL: Say “I” not “we”
General Mental Status

Weight
● Pre-pregnancy weight (kg) 120lbs
● Preg/current weight (lb) 4ft
Height
BMI (pre-pregnancy) BMI: 36.6- Obese 2 (Pacheck)
Vitals BP (140/90; Sev - 160/110) BP: 110/70

Gestational HTN: ≥140/90 mmHg after 20 weeks; HR: 78
RR: 20
occasions at least 4 hours apart with proteinuria Afebrile
HR
RR
Temp
HEENT Conjunctiva Pink palpebral conjunctiva

Sclera
Exophthalmos
Nasal discharge
Thyroid/neck mass
Cardio Precordium Normal CV findings

Apex Beat Adynamic precordium
Heaves
Lifts
Thrills
Murmurs
Respi Chest Expansion Symmetrical Normal

Tactile fremiti
Clear Breath sounds
Wheezes
Crackles
Breast Inspection Normal

● Symmetry
● Gross lesion
● Skin dimpling
Palpation
● Mass
● Tenderness
Abdomen Inspection Inspection: abdomen is flabby

● Shape Palpation: No mass, tenderness
● Scar (Mcburney, Pfannenstiel/ (-) CVA tenderness
Suprapubic transverse incision,
Midline vertical incision)
Tenderness
suprapubic pain
Fundic Ht (12,16,20)
Leopold’s (28)
● LM1 (Fundic grip)

● Mild/mod/severe
● Duration
in 60 minutes


abruptio placenta
Pelvic External Genitalia Cervix violaceous - Chadwick’s sign TCL: don’t ask hair pattern
● Inspection (Hair pattern, Lesions, No erythema
Erythema, Discharge)
● Palpation (mass, inguinal
lymphadenopathy)
Speculum
● Cervix = Violaceous/pink, smooth, fish/donut,
discharge, erythema
● Vaginal wall = violaceous or pink
○ no need to be done in F. check-ups, unless CC
is vaginal discharge, pruritus
● PPROM
○ clear fluid flowing from the cervix
○ malodorous discharge

tenderness Cervix nontender
○ TERM:
long , soft, closed
● Cervix soft, long
● Dilatation
● BOW
● Presentation
● Station
○ In Labor
○ To check for cervical dilatation =
○ We should NOT palpate on the cervical
os cos might stimulate contractions
○ Instead, palpate the fornices and
● Uterus
○ Don’t check for ante-/retroversion
○ Just check for SIZE Uterus
■ Slightly enlarged = 8wks (9-10wks - 12wks AOG (midway between umbilicus
LNR) and symphysis pubis)
■ Midway (accdg to TCL): 12 wks Adnexa
AOG No masses and tenderness
● Adnexa (if possible; only if )
Bishop
Pelvimetry
● Inlet:
○ Engaged head?
● Midpelvis:
convergent)
○ Sacrum curved
● Outlet:
Extremities Pulses full and equal in all extremities

*don’t forget this if
LNR

Primigravid, Pregnancy, 12-13 weeks AOG by LMP, Cystitis, Obese class 2 No need to say early
pregnancy (AOG will be
stated)
State the diagnosis by

order of priority
Pain at end of urination -

cystitis (bladder contracts
at end of urination)
Pain at start of urination -

urethritis

● 22 y/o ● No vaginal bleeding Diba medyo mainit po

● CC: Dysuria started yesterday ● No flank pain siya? Nabanggit niya
● (+) urinary frequency ● Afebrile kanina sa HPI, kaya
nasabi ko kanina pyello
hehe wala ata cva kaya
mas further naisip na
cystitis Oh okay sige sige
:) thanks!
Other salient features: Cervix is violaceous (Chadwick) Since AOG is 12wks,

● No danger signs of pregnancy Uterus enlarged to AOG establish pregnancy by
● LMP: June 1, 2021 Doppler for FHT
● PMP: May
● (-) PT
● No probable signs of pregnancy?
● No comorbidities
● No medications
● No previous surgeries
Ddx 1
Manifestations
Why Rule In Ddx: Acute Pyelonephritis
Why Rule Out
Ancillaries
Management
RULE IN RULE OUT
Dysuria Spiking fever, chills (Patient is afebrile)

Urinary frequency Nausea and vomiting (no nausea and
vomiting)
Risk factors: Flank pain (no flank pain)
Nulliparity, Young age (-) CVA tenderness
Ddx 2 Terminal dysuria because

Manifestations of contracted bladder after
Why Rule In Ddx: Cystitis (MAIN DX) urinating
Why Rule Out
Ancillaries
Sudden onset Dysuria (Terminal)

Urinary frequency
No fever and chills (usually without
fever)
Ddx 3
Manifestations
Why Rule In Ddx: Urolithiasis
Why Rule Out
Ancillaries
Dysuria
Urinary frequency
Vaginitis, urethritis can also cause dysuria
Suggestions
Ancillaries For Baseline ● Handheld Doppler - to check for fetal Statins - Category X
● CBC (N in preg: ≤14,000-16,000 heart tones (since patient has already
WBC) reached beyond 10 weeks)
● Blood Typing (and of partner) ● CBC - check for anemia, infections
● Urinalysis
(leukocytosis) especially that this is a
● FBS
● HIV (3rd trim) urinary tract infection
● HBSAG (3rd trim) ● Urinalysis - check for pyuria, bacteriuria
● VDRL/RPR (3rd trim) ● Urine culture - gold standard; but no
Ultrasound need to wait on the result before giving
● Ectopic - Ring of Fire empiric antibiotic
● H-mole ○ Urine Gram Stain - alternative
○ Complete - Snowstorm ● As part of 1st prenatal diagnostics:
○ Incomplete - Thickened ○ CBC (mentioned above)
○ FBS
tissue
○ BT
● Lipid Profile
(24 weeks AOG)
Treatment 1st trimester FOR CYSTITIS Cefalexin na agad

HPN in preg ● Folic Acid - .4mg/4mg (1 month prior to ● Cefalexin 500 mg QID for 7 days - Start empiric
Aspirin
● TCL: stock dose/for pt pregnancy - 14 wks) (empiric therapy) treatment then
with HPN: 80mg (for ● Multivitamins 1 tab OD ● Follow-up urine culture 1-2 weeks after shift when
doctors completing antibiotics; monitor monthly bacteria that
trimester (best time) ● Multivitamins 1 tab OD until delivery grow is not
Ca supplement ● Calcium carbonate/Milk sensitive to
● to prevent chronic HPN given
to progress ino
24-34 weeks
FOR OBESITY medication
preeclampsia
● Betamethasone 12 mg given IM 24 hours ● Proper diet; advice which ones to earlier
GDM
● Monitor 2 weeks if diet apart for 2 doses avoid, and how frequent the meals are
and exercise can control ● Dexamethasone 6 mg given IM every 12 ● Exercise
insulin ● Don’t give statins cos these are category
24-32 weeks x in pregnancy
● MgSO4 - upto 32 wks only
● IV (4-1): 4g slow IV push via infusion
pump for 20-30 mins then 1-2 g/hr for 24 FOR PREGNANCY
hours or until delivery whichever comes ● Multivitamins
first
● IM (4-5-5): 4g slow IV push via infusion ● Folic acid 0.4 mg
Follow-up schedule Advice to watch out for danger signs

of pregnancy
Advice for ff-up:

● Normal Pregnancy
○ <28 weeks -
monthly
○ 28-36 weeks -
every 2 weeks
week
● High-risk preg
○ More frequently
○ Every 1-2 week
intervals

Suggestions
Admission date - August 24, 2021 10:00 AM No indication for admission

Name - E.A.

Diet - NPO
Refer accordingly
CARES Notes
For the case earlier, we have a 22 y/o primigravid patient who came in with a chief complaint of "masakit na pag ihi". She
noted this 1 day prior to consult. She also reports having urinary frequency. No bleeding, passage of stones, back pain,
nausea & vomiting were noted. She has no comorbidities, does not take any medications and has no history of previous
surgery and transfusion. She is a non-smoker, non-alcohol drinker and denies intake of any illicit drugs. Her last menstrual
period was June 1-4 2021. No pregnancy test was done.
On Physical exam, She is noted to have a BMI of 36.6 which is classified under Obese class 2. She has stable vital signs.
Her HEENT, cardio, respiratory, and breast exam were unremarkable. Abdominal exam showed that the abdomen is flabby,
no mass, no tenderness and no CVA tenderness. On speculum exam, cervix was violaceous (Chadwick's) and on internal
exam, it was noted to be long, closed, soft and nontender. Uterus is enlarged to AOG (12 weeks AOG:midway between
umbilicus and symphysis pubis) There was also no adnexal mass nor tenderness.
Their clinical impression was Primigravid, Pregnancy, 12-13 weeks AOG by LMP, Cystitis, Obese class 2
For the management, they initially checked for fetal heart sounds via handheld doppler. Then they also requested for CBC,
Urinalysis, Urine culture (gold standard),FBS,BT, and Lipid Profile
Bile sequestrants lang daw ata pwede - Cholestyramine ?
To address her cystitis, they started empiric treatment with Cefalexin 500 mg QID for 7 days then they could shift when
bacteria seen on culture is not sensitive to the given medication. For the patient’s obesity, they would advise proper diet and
exercise.
CARES:
For my comments, their history taking and physical exam were systematic, however they failed to extract all the information
they need from the patient’s chief complaint. So since the patient’s chief complaint was dysuria, they should’ve asked when
does the patient feel the pain. Is it at the start or towards the end? As this would help in making their diagnosis later on.
Pain at end of urination - cystitis (bladder contracts at end of urination)
Pain at start of urination - urethritis
Also, I noticed that they used some medical jargon that the patient might not understand like when they asked if the patient
already had her PT. The patient was a bit confused as to what the interviewer meant so it’s better to just say pregnancy test
instead of PT. Also throughout the history they mentioned “review of systems” and “easy fatigability” as it is instead of
translating it to something the patient would have comprehended better. (example: Napansin niyo po ba na mabilis na po
kayo mapagod?)
For some learning points, one would be to not ask things that will be appreciated in the PE. This was reiterated earlier since
on ROS, the interviewer checked for pallor and edema and these things could've been noted on PE.
Lastly, On making the diagnosis, one learning point would be stating it in order of priority so I would know which problem of
the patient I should address first.
Bishop Scoring
Fetal Growth/IUGR
TSH Thyroid Labs

HEADSSSS

Twin Pregnancy
NAME: ACT AGE: 35 BIRTHDATE: DATE: August 24, 2021
ADDRESS: SEX: F CIVIL # OF YEARS RELIGION: Catholic

STATUS:Married MARRIED:
OCCUPATION: Housewife EDUCATION: 2 yr secretarial NATIONALITY: Filipino
CC: follow up prenatal care

● ONSET:
● LOCATION:
● DURATION:
● AGGRAVATING
● ASSOCIATED:
● RELIEVING
● TEMPORAL
● SEVERITY
LMP:Jan 8-?
PMP:
AOG: 32-33 weeks
4th check up now
UST lahat (previous check ups)
G2P1 (1001)
1. (-)HEADACHE
3. (-)PROLONGED VOMITING
4. FEVER
5. (-)NONDEPENDENT EDEMA
7. (-)DECREASED FETAL MOVEMENT
8. (-)DYSURIA
9. (-)BLOODY VAGINAL DISCHARGE
10. (-)WATERY VAGINAL DISCHARGE
1st:
Hgb: 10.5: abnormal (11 cut off for 1st tri)
2nd: 20-21 weeks
3rd: 23-24 weeks

Hgb: 10? - abnormal (cut off 10.5)
OBSTETRIC TOTAL PAST PREGNANCY: 1 FULL TERM: PREMATURE: ABORTION: ALIVE: OB SCORE:
HISTORY 1 0 0 1 G2P1 (1001)
1. 2019 nsd? -
Term 6lbs
NOTES:
2.
NOTES:
3.
NOTES:
MENARCHE COITARCHE 32
INTERVAL NO. OF SEXUAL 1

PARTNERS
DURATION
POST-COITAL
AMOUNT BLEEDING
SYMPTOMS DYSPAREUNIA
CONTRACEPTIVES
USE
LMP Jan 8 2021
PMP
AOG 32-33 weeks aog
EDC Oct 15, 2021

SURGERIES, none DM
TRANSFUSION
HPN Mother
OB & GYN
PROCEDURES CANCER
Others:
HOSPITALIZATION none Asthma - father
IMMUNIZATION Waiting list COVID

(Childhood, Hepa
B, Covid)
COMORBIDS Htn, dm, thyroid, cancer, asthma
MEDICATIONS none

11. HEADACHE
SMOKING No
ALCOHOL No (occasional lang before) 13. PROLONGED VOMITING
14. FEVER
COFFEE 15. NONDEPENDENT EDEMA
DRUGS 17. DECREASED FETAL MOVEMENT
18. DYSURIA
DIET 19. BLOODY VAGINAL DISCHARGE
20. WATERY VAGINAL DISCHARGE
EXERCISE
REVIEW OF SYSTEMS:
GENERAL
SKIN, HAIR, NAILS
EYE
EAR
NOSE
MOUTH
CARDIO
PULMO
GASTROINTESTINAL
GENITOURINARY
HEMATOLOGY
NEUROLOGIC
ENDOCRINE
MUSCULOSKELETAL

○ MENTAL STATUS: AMBULATORY, NOT IN DISTRESS, conscious, ○ INSPECT THE VULVA (EXTERNAL GENITALIA)
coherent ■ SCARS
○ BODY HABITUS: ■ ERYTHEMA
○ WEIGHT: 136 lbs (120 last pncu) ■ BLEEDING
○ HEIGHT: ■ DISCHARGE
● VITALS SIGN: di ko nakuha ang bilis sorry hhuhu (normal naman ba? ■ MASSES
○ BP: ■ RASH/ VESICLES/ ULCERATIONS
○ HR: ■ PUBIC HAIR DISTRIBUTION
○ RR:
○ TEMP: 36.7 ○ SPECULUM EXAM (INSPECT THE CERVIX)
● ANTHROPOMETRIC DATA ■ SMOOTH, VIOLACEOUS
○ HEIGHT: 5’3” ■ DISCHARGE
○ WEIGHT: pre-preg 120 , march 31 132lbs -> now 136lbs
■ Gross lesions of the walls of the vagina
○ BMI: 21 Normal
● (HEENT) EYES: ■ CERVICAL ECTROPION
○ PINK PALPEBRAL CONJUNCTIVA: Patient slightly pale ■ ULCERS
○ Anicteric sclerae ■ MASSES/POLYP
○ exopthalmos ○ INTERNAL EXAM
○ No other deformities ■ CERVIX
○ No acne, discoloration ● soft, long, closed,
○ No neck mass, neck is supple
● Cervical motion tenderness
○ No tracheal tenderness
○ No oral discharge, No nasal discharge ■ UTERUS
● CARDIO: unremarkable ● Uterus normal sized (if enlarged, ask for how many
○ ADYNAMIC PRECORDIUM, no HEAVES, LIFTS, THRILLS months size?),
○ PMI left 5th ICS, MCL ● Tenderness
○ Normal rate, normal rhythm ● Anteverted
○ No murmurs ● Movable
● RESPIRATORY: unremarkable
● consistency
○ SYMMETRICAL EXPANSION, NO LAGGING, NO WHEEZES,
○ Clear breath sounds ■ ADNEXA - (do not palpate if >14 wks AOG- would not be
○ No rhonchi palpable)
● BREAST: ● palpable mass
○ INSPECTION: ■ CUL-DE-SAC - fornices are deep?
■ symmetrical ■ BISHOP’S SCORE
■ SWELLING ● Dilatation:
■ MASSES ● Effacement:
■ SKIN CHANGES ● Consistency:
■ NIPPLE CHANGES ● Position:
○ PALPATION: ● Station:
■ ASYMMETRY ■ CLINICAL PELVIMETRY
■ SWELLING ● INLET: true, obstetric, diagonal conjugate (>11.5 cm)
■ MASSES ● MIDPELVIS: ischial spine not prominent, curved
■ EXAMINE AXILLARY LYMPH NODES sacrum, walls divergent
● SIZE ● OUTLET: wide pubic arch, fist can fit the bituberous
● CONSISTENCY diameter (>8cm)
● FIXATION
■ EXAMINE REGIONAL LYMPH NODES
● INFRACLAVICULAR ● RECTAL EXAM
● SUPRACLAVICULAR ○ INSPECTION
● CERVICAL ■ SKIN EXCORIATION
● ABDOMINAL ■ RASHES
○ INSPECTION: globular, reddish striae on lower part ■ HEMORRHOIDS
■ ANAL FISSURE
■ FEMALE ESCUTCHEON
■ BLEEDING
○ PALPATION:
■ FISTULAE
■ No Direct and rebound tenderness
■ ABSCESSES
■ Masses (cystic/doughy, firm, movable/fixed)
○ PALPATION
■ FUNDIC HEIGHT: 29 cm, ● RECTOVAGINAL EXAM
■ LEOPOLDS (28weeks) ○ PALPATION
● LM 1(Fundal): buttocks buttocks ■ NODULARITY
● LM2: (Umbilical) : Fetal back onleftleft ■ TENDERNESS
● LM3: (Pawlik’s): cephalic ■ MASSES
● LM 4 (Pelvic)
○ AUSCULTATION: NORMOACTIVE BOWEL SOUNDS
■ FHT: (N:110-160) 150 bpm regular
● EXTREMITIES: presence of edema; +1 bipedal edema
○ physiologic at term bc of venous compression

● HEENT:
● GI:
● GU:
35 y/o G2P1 (1001) 32-33 weeks AOG (-) danger signs of pregnancy
● MSK:
Came in for her 4th prenatal check up Unremarkable PMH
● NEUROLOGIC:
Family History of No cough and coughs, no easy
● Hypertension (mother) fatigability
● Asthma (father) No previous surgeries
+1 bipedal edema - more prominent in Non-smoker, occasional alcoholic
the afternoon; none in the morning drinker
Unremarkable heart and lungs
CBC on the 1st and 3rd prenatal check
up:
● Low Hgb (10.5 and 10)
(+) Slight Pale palpebral conjunctiva
BMI = 21 (normal)
Fundic Height = 29 cm not compatible

with AOG
TENTATIVE DIAGNOSIS/ FINAL DIAGNOSIS: G2P1 (1001) Pregnancy uterine, 32-33 wks AOG, cephalic, t/c Fetal Growth Restriction, t/c IDA,

Anemic
1st prenatal 10.5 (cut off 11)
2nd prenatal 10 (cut off 10.5)
Slight pale palpebral conjunctiva

Weakness
Loss of appetite
Growth restriction - FH now not compatible with AOG (29 cm at 32 wks AOG); weight gain__
1. Iron Deficiency Anemia Slight Pale Palpebral Conjunctiva

Low Hgb (10.5 and 10)
Pt is in 3rd tri (N: 11.5g/dl)
2. Fetal growth restriction FH: 29 cm at 32-33 weeks lmp AOG by early UTZ, not just LMP
Early ultrasound 9-10 wks AOG at March 15
● 32 - 33 weeks AOG
Now is August 24 so
Mar 31-15 = 16
Apr 30
May 31
June 30
July 31
August 24
Total: 162/7 = 23 wks + 9-10 wks = 32-33 wks
32 cm dapat +-2cm
- This is 3 cm difference
Weight gain of patient 120 → 132 lbs

- 12 lbs in 2 wks (large)
- 3rd prenatal - 23-24 wks (weight should have
been asked)
- Less appetite and feeling weak, pale
palpebral
3. Constitutionally small fetus
4. Transverse lie Leopolds maneuver: Cephalic presentation
5. Oligohydramnios
6. PROM Smaller FH No watery discharge
7. Wrong Dating of AOG Dating by UTZ

UTZ dating of AOG is compatible with LMP dating
8. Chromosomal abnormalities (-) CAS

● Repeat cbc - check hgb again for the anemia 32-33 weeks AOG
● ABO typing with rh - in case patient needs transfusion because of 1. Evaluate maternal status and comorbidities: patient is anemic
anemia
● Urinalysis - check for underlying infection PNCU:
● Fetal biometry: check for BPD, AC, FL
● BPS with doppler velocimetry - For antenatal surveillance fetal status Give antenatal corticosteroids to hasten lung maturity - wag muna if di pa
○ We want to prolong pregnancy up to 34 wks at least idedeliver?? Yeahhhh
- Betamethasone 12 mg IM every 24 hours, 2 doses
Hypoxia - Dexamethasone 6 mg IM every 12 hours, 4 doses
Restrict oxygen circulation → oxidative stress hypoxia → fetal growth
Maternal anemia is not an indication to deliver!
restriction
Increase ferrous sulfate to BID/ iron sucrose parenteral. Or may give
parenteral.
i. Antenatal surveillance Repeat Biometry UTZ after 2 weeks
1. Fetal movement counting Refer to dietary for nutrition
2. BPS, NST Improve nutrition
3. Doppler velocimetry studies Requested for HBsAg?______
4. Fetal growth monitoring by ultrasound every 3-4
weeks
ii.
Percentile
iii. Indications for delivery:
<10%? ng e
1. Non-reassuring fetal tracing
2. Reversed end-diastolic flow
xpected?
3. Maternal or obstetrical indications for delivery
Umbilical artery Doppler velocimetry -
iv. As long as there is interval fetal growth and fetal
surveillance test results are normal, pregnancy is allowed to
continue. Deliver only when there is an indication to
deliver.
1. Reassessment of fetal growth is typically made no
sooner than 3-4 weeks
Prescription
●
Follow up
MONITOR BIOMETRY every 2-4 weeks!!!
ADMIT ADMIT Admit to (OB ward, surgical ward, OR)

DIAGNOSIS DIAGNOSIS Diagnosis
CONDITION CONDITION Serious, guarded, critical, stable, etc
VITALS VITALS Check vitals every 15 mins, etc
ACTIVITY ACTIVITY Bed rest, bed rest w/ bathroom privileges, crib
NURSING ORDER no restrictions, etc
DIET NURSING ORDER For nurses to routinely do
IV FLUIDS DIET NPO, 1000 calorie, no salt, special diets, etc
MEDICATIONS IV FLUIDS Ex. D5 .2 NS + 20 mEq/L of KCL to run at 14
cc/hr
LABS
MEDICATIONS Medications should include name, dose, route
CALL HO
and frequency. Oxygen is included here.

LABS LABS
CALL HO Red flags or warning signs
Ex. if HR <60 bpm
Share Screen:
Notes for Cares:

- Clerk was able to ask for the danger signs of pregnancy
- Clerk was able to ask for the previous laboratories since this is the 4th PNCU
- Spontaneous Delivery is used, it would be better to ask not use medical jargon
- Clerk was able to ask patient to void before start of PE
- Pay more attention sa Ultrasound so that you can correlate the Hx and PE.
Doc’s Comments:
- Introduce ourselves as part of the medical team so we can get the rapport of the patient
- Second prenatal care and ask the results
- MIDAS not necessary, take a focused history and PE because of limited time
- Compute for sonographic aging also if the with the LMP (differentials is wrong dating, transverse lie, oligohydramnios, genetically small, ruptured membranes)
- Maternal weight gain should be correlated with the AOG to assess for the IUGR
- V good sa doppler
Comments from CARES:

Ask for management since first visit
Ask for compliance with medications such as ferrous sulfate
Consider thalassemias as differential diagnosis if iron is still low despite compliance with medications
To check if patient is compliant with iron: ask patient’s stool color (will be very dark if she is taking iron)
Aside from umbilical artery, also check middle cerebral artery for anemia
No need to do IE if there are no indications (indications such as bleeding),
Routinely do IE if patient is already term every week until delivery (37 weeks onward to check for dilatation)
Facilitator: TCL
Clerks: Lapenas, Lara
Date: 8/24/21
Sources:
[GYN] Skills 1 - History Taking

https://drive.google.com/file/d/1yz7c6xsM3QnrkJUogx_Ey6AS6HBX3g2k/view
[GYN] Skills 2 - Breast and Pelvic Exam

https://drive.google.com/file/d/1e114TTTErJw0AexZXUOmcTIhkFmdzrKr/view
FOCUSED HISTORY TAKING
Intro: INTRODUCE SELF ONLY
General Data Name: rm

Age: 36
If obstetrics: Birthday:
Ask gravida and para already
Birthplace:
Address:
Marital Status:
Nationality:
Religion:
Occupation: Online seller
Educational Attainment:
Chief Complaint: Follow-up
CBC Hg: 11, hct: 30 plt : adequate WBC 0.7, Eosinophil 0.5
Urinalysis: cloudy, bacteria +3, pus +1
FBS: 200 mg/dL - overt DM(>126 mg/dl)
Lymp .7
AOG:11-12 AOG
3rd prenatal check up - current
No pregnancy test yet
History of Present Illness: O-

Kailan po ito nagsimula? (Anong oras? Naranasan niyo na po ba ito dati?)
LMP- Jun 2, 2021 L-
PMP- Apr 30, 2021 Saang banda niyo po ito nararamdam? Pwede niyo po bang ituro sa akin? Dyan lang
po ba nararadaman yan o may ibang parte pa ng katawan kung saan ito ay
kumakalat?
Nagpregnancy test na ba D-
Gaano katagal niyo po ito nararamdaman
10 DANGER SIGNS OF
C - Pwede niyo po bang ilarawan sa akin kung paano _____?
PREGNANCY
1. Persistent headache NONE A-
Ano po yung ginagawa niyo bago niyo maramdaman ang sintomas na yan? Sa tingin
2. Blurring of vision NONE niyo ba may bagay or gawain na nagpapalala ng inyong sintomas?
3. Nausea and vomiting NONE Relieving -
4. Fever and chills NONE Ano pong ginawa niyo para mawala ang sintomas na yan? May ininom po ba kayong
5. Epigastric Pain/Hypogastric Pain gamot?
NONE T-
6. Dysuria NONE May pinipiling oras po ba ito?
7. Decreased fetal movement S-
8. Watery Vaginal Discharge NONE Gaano po ito kalala, sa bilang ng 1-10, 1 bilang pinakamababa at 10 bilang
9. Bloody Vaginal Discharge NONE pinakamataas? Lumalala po ba ito?
10. Nondependent edema/Swelling
of the hands and feet that is May iba pa po ba kayong mga sintomas na nararamdaman?
non-resolving -
Other History
OB-GYNE History
Menstrual History:
G1(2016) - Incomplete abortion at 8 weeks AOG with completion
LMP- curretage
PMP- G2 - current pregnancy
MIDAS (menarche, interval,

duration, amount, M - about 11/12 years old
symptoms) I-
- Menarche: Ilang taon po
kayo nung una kayong
rinegla?
- Interval: mga ilang araw
ang interval or pagitan?
Regular?
- Duration: Ilang araw ang
tinatagal non?
- Amount: Nakakailang pads
po kayo sa isang araw.
Gaano po siya kapuno or
soaked?
- Symptoms: May mga
napapansin po ba kayong
mga sintomas tuwing kayo
ay dinudugo?
Medications taken
() Regular
() Missed menses, May buwan po
ba na hindi kayo dinatnan ng regla?
() Intermenstrual bleeding,
Dinudugo po ba sila ng labas sa
mga araw ng pagreregla ninyo?
1. - G2 P0
G1 (5 years ago) - abortion,8 weeks AOG, D&C

Prenatal check up Complete vaccinations? Siguro daw huhu
- COVID - yes 2 doses
When is the first and last consult? - HPV - none
Who did and where was it done?
How frequent? -
Previous laboratories done -
- CBC, platelet count
- Blood typing
- HBsAg
- VDRL / RPR
- HIV Testing
- Screening for DM
- Ultrasound (date done)
Prenatal/Immunizations given
- Tetanus Toxoid
- Hepatitis B
- Influenza
- Pneumococcal
Medications prescribed
- Multivitamins/ Prenatal milk
- Folic acid supplement
(usually given at 8th week)
- Iron supplement (2nd
trimester)
- Calcium
Gynecologic History:
History of STI/STD?
Diseases of female reproductive
part (including breast)
- History of discharge?
Vulvar itchiness?
Ulcerations? Warts?
Pap smear with dates and results
Sexual History
Coitarche:
No. sexual partner/s:
Occupation of Partner/s:
Regularity:
Satisfaction:
Associated symptoms:
dyspareunia, post-coital bleeding
Date of last sexual contact:
Contraceptive History
Type of contraceptive used:

Generic/brand name:
Duration of use:
Reason for choice:
Satisfaction with method:
Effectiveness:
Undesirable side effect:
If already stopped, Date?
Reason for discontinuance?
Past Medical History:

Seafood allergy
Allergies
Cardiac Disease 140/90 mmHg
Highest: 150/90
Diabetes
With medications: unsure, not monitored
Epilepsy
Exposure to Rubella Gonorrhea Surg - appendicitis
Hepatitis
Hypertension Immunization
Renal Disease
Thyroid Disorder Tuberculosis
Current medications
BLOOD TYPE:
____Patient _____Husband
Surgical History
A. Diagnosis
B. Date of operation and type of
operation
C. Surgeon and hospital where
performed
D. Histopathological result
E. Outcome
Family History:
DM, HTN, CA (breast, cervical,
endometrial, ovarial), asthma, heart
diseases, PCOS
Personal and Social History: Medications:

- Losartan - start taking 5 yrs ago, 50mg, BID, compliant
Diet:
Activity Level/Exercise: 140/150/90 usual bp
Smoking: 150/90 highest bp
Alcohol Intake:
Illicit drug use: Diet - kanin, steak
Exercise - wala
Smoking - none
Drinking - none
Drugs - none HAHA
ROS Weight change: unsure, not measured

Change in sleep: none
● General: weight change (loss or Appetite:
gain), fever, headache, chills,
malaise, change in appetite,
change in sleep pattern
● Cutaneous:
● itchiness, color change,
hyper/hypo/depigmentation,
photosensitivity
● rash or eruptions, vasomotor
change, texture change, mole
change, excessive sweating
● hair - growth, loss, thickness,
brittleness
● Nail - growth, color
● HEENT: Headache; dizziness;
○ Eye: blurring of vision,
photophobia, doubling of
vision, redness, itchiness,
pain, lacrimation, periorbital
swelling, history of trauma
○ Ear: deafness, tinnitus,
discharge, otalgia(ear pain)
○ Nose: epistaxis, discharge,
obstruction,abnormal sense of
smell,colds, postnasal drip,
sinus pain
○ Mouth: bleeding gums, dental
pain,soreness of tongue,
fissure, tongue
abnormality,disturbance of
taste (e.g. metallic taste),
toothache, salivation; bleeding
gums, tongue fissures or
abnormality
○ Throat: Soreness, tonsillar
pain, hoarseness or change in
voice, dysphagia
● Neck: stiffness, limited ROM, lump
in throat
● Breast: mass, pain, discharge,
galactorrhea,change in the color of
the areola, tenderness, trauma,
skin change, skin dimpling,
● CV: chest pain, easy
fatigability,paroxysmal nocturnal
dyspnea, orthopnea,palpitations,
syncope,leg edema
● Respiratory: dyspnea, shortness
of breath,cough, sputum (character
and quantity) production,
hemoptysis , cyanosis,
wheezing,chest pain related to
respiration, back pain, chest wall
abnormality
● GI: (-)
○ nausea, vomiting, retching,
hematemesis,
○ belching, indigestion, food
tolerance, jaundice, heartburn,
flatulence
○ abdominal pain, abdominal
distention, abdominal mass
○ diarrhea, constipation,
melena, hematochezia,
○ anal lesion, hemorrhoids,
change in stool color or
contents (clay-colored, tarry,
fresh blood, mucus,
undigested food)
● GU: (-)
○ urgency, frequency, urgency,
hesitancy, dribbling, weak
urinary stream, urinary
incontinence,
○ dysuria,hematuria,
nocturia,polyuria, oliguria,
anuria, flank or suprapubic
pain, stone passage, sandy
urine, bubbly urine,edema or
swelling(periorbital, facial,
bipedal),
○ urethral discharge, vaginal or
cervical discharge,genital
lesion, testicular mass
○ perineal pain, perineal
mass,vaginal bleeding,
erectile dysfunction, hernia
● Endocrine:
○ heat-cold intolerance,
palpitations, breast change,
voice change,
○ polydipsia, polyphagia,
polyuria
○ irritability, slowness in
mentation,distribution and
changes in facial or body hair,
increased hat or glove size
● Nervous/Behavioral:
○ headache, seizures, loss of
consciousness,
○ abnormality of sensation,
motor dysfunction or
weakness or paralysis,
○ abnormality of coordination,
speech disturbance, mental
change, head trauma,
tremors, loss of memory or
ability to concentrate
● Musculoskeletal: joint stiffness,
pain, swelling, muscle pain,
cramps, muscle weakness, muscle
wasting, abnormal posture
● Hematopoietic: abnormal
bleeding, bruising, pallor,
adenopathy
● Psychiatric:
○ anxiety, depression,
hallucination, delusion,
paranoia,violent behavior,
mood change,difficulty
concentrating, agitation,
tension, suicidal thoughts,
irritability, sleep disturbance
FOCUSED PHYSICAL EXAM

*ask patient to void urine prior to conducting PE
General Survey Conscious coherent oriented
Ambulatory
Mental Status:
- Conscious, coherent,
oriented to 3 spheres,
ambulatory, not in
cardiorespiratory distress
Vital Signs
BP: 140/90
HR: 86
RR: 20
Temp: 36.9
Sp. O2:
Anthropometric Data
Height: 5’4
Weight:(pre-pregnancy, current)
135lbs
BMI:
Pre-pregnancy:
Current:
- Asia-Pacific
- <18.5 =
Underweight
- 18.5 - 22.9 =
Normal
- 23 - 24.9 =
Overweight
- >/= 25 = Obese
Skin
Warm to touch
Appropriate skin turgor
Pallor (-)
Cyanosis (-)
Active dermatoses
Ecchymoses
Acanthosis nigricans
HEENT
Chloasma
Melasma
Pink Palpebral conjunctiva (color)
Epulis
Head: Lesions, gross deformities,
facies, evenly distributed hair
Eye: Pink palpebral conjunctivae,

anicteric sclerae, periorbital
edema, drooping of eyelids,
fundoscopic exam (papilledema),
any diplopia,
Ears: Tragal tenderness, aural

discharge, intact tympanic
membrane AU
Nose: Nasal septum midline,

non-hyperemic nasal mucosa,
turbinates non-congested, no nasal
discharge, sinus tenderness
Mouth, Throat, Oropharynx: Pink

lips, moist buccal mucosa, oral
ulcers, tonsils not enlarged and
non-hyperemic, exudates,
non-hyperemic posterior
pharyngeal wall
Neck: Trachea in midline, NO

palpable anterior neck mass,
palpable cervical lymph nodes,
thyroid enlarged, neck veins not
distended, carotid bruit
Chest and Lungs unremarkable
I: NONE Gross deformity of the

chest, chest retractions, use of
accessory muscles, symmetry of
the appearance of the chest
Pa: Symmetry of chest expansion

(symmetrical or asymmetrical),
tactile fremitus (normal, increased,
decreased)
Pe: (dull, resonant, hyperresonant)

normal
A: Breath sounds normal,

adventitious breath sounds
(crackles, wheezes, ronchi,
bronchial/tubular, pleural friction
rub, stridor)
Heart- normal unremarkable
I: Precordium (dynamic,
hyperdynamic, adynamic),
presence of precordial bulge, any
visible pulsations on the chest,
where is the apex beat located
Pa: Presence of thrill, substernal
thrust, pulses (decreased,
bounding, absent or weak, any
radio-femoral delay)
A: Murmur, what is the grade if
present
Breast
DON’T FORGET TANNER STAGING Unremarkable
MOST ESPECIALLY IF
PEDIATRIC/ADOLESCENT PATIENT
• Wash hands
• Introduce yourself
• Confirm patient details
• Explain Examination
• Gain Consent
• Ensure a chaperone is present
- Male gynecologist - should be
accompanied by a female
assistant
• Expose patient
• After examination: Thank Patient,
Wash Hands
• Self-breast exam is recommended
once a month after menstruation
- Best time: 1 week after
menstruation
▪ Hormone has less effect in the breast
- While woman is taking a bath
• Clinical (done by the physician) breast
exam once a year or every 2 years
together with pap smear
• OB-GYN - only perform diagnostic
- If biopsy is needed, refer to
surgeon
• High risk for breast CA = request
mammography at age 40
• Not high risk = request mammography
at age 50
• Non-palpable lesions can be detected
in mammography
I:
Any gross abnormality on
the breast
Asymmetry (before
assuming asymmetry,
always ask if it is always
have been asymmetrical;
the dominant side usually
appear larger than the
other side)
Swelling
Masses
Skin Changes
Nipple Changes
Pressing into hips
(Contraction of
Pectoralis Major)
Hands behind head
Push elbows back
and lean forward
(will exacerbate
skin dimpling)
Pa:
Asymmetry?
Swelling?
Mass?
Location
Size/Borders
Consistency
Fluctuance
Fixation
Examine Axillary Lymph
Nodes
Size
Consistency
Fixation
Examine Regional Lymph
Nodes
Infraclavicular
Supraclavicular
Cervical
Abdomen Fundic height

Fetal heart tones
I: Size, shape, describe striae Fetal movements
(color), scars (location, length,
hypertrophic vs keloid), paradoxical Inspection:
breathing, any prominent vessels Abdominal shape: globular? Flabby? Flat?
(distended veins), pulsations, RLQ Scars/surgical scars -
peristaltic waves Fundic height: N/a
A: Character and frequency of Palpation:

bowel sounds NO Direct or rebound tenderness each quadrant (RUQ, LUQ,
IF ALREADY >/= 20 RLQ, LLQ), No masses
WEEKS Guarding
Auscultation: FHT= ___ Rigidity*? - sign of peritoneal irritation
bpm located on the ___,
note for regularity. Palpate uterus:
12 weeks gestation: pubic symphysis
Pe: Tympanitic, dull, resonant 20 weeks gestation: umbilicus
36 weeks gestation: the xiphoid process of the sternum
Pa: Mass palpated, tenderness, - Consistency: soft, boggy, doughy, firm,
rigidity, guarding
Leopolds Maneuver: Don’t do yet SKIP
LEOPOLDS LM1 (Fundic grip)
Palpation: Fundic Height = __cm LM2 (umbilical grip)
EFW= __kg LM3 (Pawlik’s grip)
LM1 (Fundal Grip) LM4 (Pelvic grip)
Determines what fetal part
occupies the fundus LM1 and LM3 = fetal presentation
Cephalic presentation: large Fetal lie
nodular body representing the
buttocks or lower extremities Auscultation:
Breech presentation: hard, freely Fetal heart tones - place stethoscope at the side of the fetal back
moveable and ballotable part
representing the head
Shoulder presentation/ Transverse
lie: empty
LM2 (Umbilical Grip)
Determines on which maternal
side is the fetal back
Fetal back: resistant convex
structure
Fetal small parts: numerous
nodulations
LM3 (Pawlik’s Grip)
Determines what fetal part lies
over the pelvic inlet
If fetal head (cephalic presentation)
is not engaged: movable, round,
hard body palpated
If lower pole of fetus is engaged,
head is fixed.
LM4 (Pelvic Grip)
Determines on which side is the
cephalic prominence
In flexion attitude, cephalic
prominence is on the same side as
the small parts
Pelvic CLINICAL PELVIMETRY SKIP
o For male physicians, always ask Ask to empty bladder

a female colleague
to accompany you Inspection of External Genitalia NONE
Gain consent - Scars (episiotomy scars)
Always ask to empty the bladder - Bleeding none
prior to the procedure - Masses none
o Except on cases on introital - Rashes/ulcerations/vesicles
mass, prolapse and
complain of incontinence IE - don’t do if bleeding in the second half of
Gather the equipment to be used pregnancy!!
o Gloves
o Speculum Speculum Exam: NORMAL
o Lubricant - Cervix: smooth
o Sample Pot - color (violaceous, pink),
o Endocervical brush - masses/gross lesions - none
(sterile spatula and - discharge (watery, bloody vaginal discharge), - copious,
popsicle stick can also be dirty white nonfoul discharge
used) - shape of external os
- parous cervical os (fish mouth) or
INSPECTION of External - nulliparous cervical os (circular)
Genitalia; Inspect the Vulva - Check for pooling of amniotic fluid in the cul de sac
distribution of hair, shaving (PPROM)
(hygienic)
Scars Internal Exam:
Erythema - Cervix consistency (soft, firm)
Bleeding - Cervical length - for dilation; instead of palpating ext. os
Discharge which might stim. UCs
Masses - Uterus normal sized (if enlarged, ask for how many months
Rash/Vesicles/Ulcerations size?), anteverted, movable, tender, consistency
*Pubic Hair Distribution - 11-12 wks (midway between symphysis pubis &
(inverted triangle, right umbilicus)
mediolateral episiotomy - Position of uterus irrelevant in this case
scar, parous opening) - Cervical motion tenderness - ectopic pregnancy -
- Parous introital opening - Bulging in the cul de sac - hemoperitoneum
- Adnexal masses or tenderness none
-
Clinical Pelvimetry DO NOT DO

- Inlet:
- Measure diagonal conjugate (N: >11.5cm)
- Sacral promontory (N: not accessible)
- Engaged head?
- Muller Hillis maneuver (station 0)
Speculum Exam (INSPECTION - - Midpelvis:
INTERNAL) - Hold the handle of - Ischial spines (N: not prominent)
the speculum with your dominant - Pelvic sidewalls (N: Divergent/ NOT convergent)
hand, and open the labia minora - Sacrum curved
with the other one (use thumb and - Outlet:
5th finger). Insert the CLOSED - Sub-pubic arch wide >90 degrees
speculum gently, sideways at first, - Bituberous diameter >8cm
then slowly rotate to the normal - If abnormal findings: contracted uterus
position, then gently open the
speculum. Inspect the cervix.
Inspect the Cervix:

Color pink smooth with
minimal whitish mucoid
discharge
Ulcers
Masses/ Polyp
Discharge (amount, color,
description)
Shape of external os
Normal Report: Cervix is pink,

smooth, no masses, lesions, or
discharge
Internal Examination
(PALPATION):
DON’T PERFORM IF BLEEDING
IN 2ND HALF OF PREGNANCY
CASE
Describe cervix according to

following:
Normal Report:
Cervix: soft long and closed
Uterus: enlarged to ____ months in
size, non tender
Adnexa - no mass or tenderness
Bimanual Exam (PALPATION):

Size (normal, enlarged; anteverted
or retroverted)
Consistency- Normal
Mass
Adnexa: mass or tenderness (-)
Asses:
Vagina - nodularity,
tenderness, masses
Cervix - open or closed,
soft or firm, short or long
Is there cervical motion
tenderness?
Uterus - size (is it
compatible with AOG),
surface (smooth/irregular),
consistency, mobility,
orientation
(retro/anteverted)
Ovaries - nodularity,
tenderness, masses
Cul-de-sac - blood or mass
D-ilatation
E-ffacement
P-osition
A-mniotic membranes
P-resentation
S-tation
PEDIATRIC GYNECOLOGIC Please input here the findings:

EXAM
---------------------------------------------------------------------------------------
● Always preceded by general Techniques
examination ● Patient Positioning
● Should be carried out at the end, ○ Frog Leg
■ Most commonly used
once the patient is comfortable w/
■ Supine with knees apart and the soles of the feet
the examiner touching in the midline
● Child should not be physically ■ Allows for the child to have a direct view of the
restrained or forced to undergo an examiner and herself
examination ○ Frog Leg w/ Guardian’s Assistance
■ For the anxious child
■ Have the guardian sit on the table in a semi-reclined
position with the child’s legs straddling her thighs
○ Knee-Chest Position
■ For the older child (>2 y/o)
■ Have the child rest her head on one side of her folded
arms and support her weight on bent knees
■ Allows for better visualization of the lower and upper
vagina and cervix
■ Normally, a closed vaginal canal opens up since the
child is relaxed
● Visualization Techniques (Vestibule/Hymen)
○ Supine Lateral Spread
■ Labia majora are spread laterally and posteriorly
enough to visualize the vestibule
○ Supine Lateral Traction
■ Labia majora are grasped gently in the same location
followed by gentle traction of the tissue toward the
examiner
● Visualization Techniques (Vagina and Cervix)
○ To establish foreign bodies, tumors, causes of vaginal bleeding
and discharge
○ Otoscope
■ Use of an otoscope to magnify tissues
■ For the prepubertal vaginal (only 4-6 cm)
■ Otoscope NOT inserted into the vagina
■ Light source from the otoscope can be aided by bright
light which helps to illuminate the vulvar area
○ Nasal speculum
■ May be used to visualize the vaginal canal and the
cervix
■ Preferably done under anesthesia
■ Painful
○ Vaginoscopy
■ Uses an endoscope with irrigation properties
■ Irrigation w/ saline to distend the vagina
■ Minor surgical procedure done under anesthesia
■ Greater magnification
■ Least trauma to hymen
■ Most ideal but most expensive because done in an
OR
Rectal Exam
• A rectal examination is primarily
done if the patient is a virgin or has
no sexual history. Do not do vaginal
exam given those indications
Inspection
Tight sphincter tone, cystic to

doughy mass (right) mass non
tender
No blood on tactating finger
Uterus slightly movable, retroverted
• Rashes
• Hemorrhoids
• Anal Fissure
• Bleeding
• Fistulae
• Abscesses
Palpation
● Lubricate the finger
○ Use the Index
Finger
● Insert the finger gently
into the anal canal
● Rotate the finger 360
degrees to assess the anal
canal
● Palpate for the
following:
○ Cervix
○ Size of the
Uterus
○ Adnexal area
▪ Ideally,
there is
nothing to
feel or
palpate in
the
adnexal
area
▪ Any mass
that can be
palpated in
the area is
considered
a
suspicious
abnormalit
y
● Shift to the right side and
left side
● Assess the anal sphincter
tone
○ Ask the patient to
squeeze the finger
● In rectal/rectovaginal
exam, you can palpate for
tender
nodularities in the
uterosacral ligaments
(endometriosis).
Rectovaginal Exam
Palpation
Palpate the tissue in
between the rectum and
the vagina (rectouterine
pouch of douglas)
Nodularity
Tenderness
Masses
For the rectal finger,
palpate the integrity of the
rectal mucosa and
presence of mass.
Rectal mass
Muskuloskeletal
Neurologic
DISCUSSION
Hx and PE ● Gen data:
○ RM
○ 36 years old
○ online seller
● CC: Follow-up (labs - urinalysis, cbc, fbs)
○ Cbc
■ Hemoglobin 11
■ Hct 0.30
■ Plt adequate
■ Lymphocyte 0.7
■ Eosinophil .05
■ PMS 0.5
■ Platelet diff normal
○ Urinalysis - cloudy
■ Bacteria +3
■ Pus +1
○ FBS 200
● HPI:
○ O-
○ L-
○ D-
○ C-
○ A-
○ R-
○ T-
○ S-
● Menstrual Hx:
○ LMP: June 2
○ PMP: April 30
○ M: 12/13
○ I:
○ D:
○ A:
○ S:
● Sexual Hx:
○
● Contraceptive Hx:
● PMH:
○ COVID vaccinated
○ Seafood allergy
○ Hypertension
■ Losartan 50mg bid for 5y
■ 140-150/90 usual bp
○ Appendicitis
● FH:
○ Diabetes lolo
○ Hypertension both parents
● Personal & Social:
○ Diet: kanin, steak
○ No exercise
○ Non-alcoholic, non-smoker, no illicit drug use
● ROS:
○
● OB history
○ G2P0 (0010)
■ Last pregnancy 5y ago
■ 2mo, completion curettage
● PE:
○ Ambulatory, not in distress
○ BP: 140/90
○ HR: 86
○ RR: 20
○ Temp: 36.9
○ Height 5 ‘4”
○ BMI: 23.2 (Overweight)
○ Pre-pregnant weight 135lbs
○ Pink palpebral conjunctiva
○ Anicteric sclerae
○ Lungs normal
○ Heart normal
○ Breast normal
○ Abdominal exam: normal
○ Pelvic exam:
■ External genitalia: normal
■ Speculum exam:
● Copious dirty white nonfoul
discharge
● Cervix violaceous, smooth
■ Internal exam:
● Cervix soft
● Uterus between pubic symphysis
and umbilicus
● No adnexal masses
● No tenderness
Salient features ● 36 years old G2P0 (0010), 5 years ago, (2 months AOG,
completion curettage)
● Follow-up
● LMP June 2 (11 wks AOG)
● PMP April 30
● Labs:
○ Hgb: 11
○ Hct: 0.30
○ Plt: adequate
○ Lymph: 0.7
○ PMS: 0.5
○ Eosino: 0.05?
○ UA: cloudy, bacteria +3, pus cells +1
○ FBS: 200
○ Blood type A negative
● 3rd check up
■ No headache
■ No Blurring of vision
■ No nausea vomiting
■ No fever
■ No epigastric pain
■ No dysuria
■ No discharge
● No pregnancy test
● 5 years ago
○ Losartan 50mg, BID, compliant, di alam kung may
relief
○ Usual BP: 140-150 / 90
○ Highest BP: 150/90
● Allergic to seafood
● No kidney problems
● Past surgery:
○ Appendicitis (date unrecalled)
● Family history
○ Lolo: DM
○ Hypertension: both parents
● Usual diet: rice, steak
● No Exercise
● Non smoker
● Non alcoholic
● ROS unremarkable (?)
● PE:
○ Ambulatory, not in distress
○ BP: 140/90
○ HR: 86
○ RR: 20
○ Temp: 36.9
○ Height 5 ‘4”
○ Pre preg Weight: 135 lbs
○ BMI: 23.2
○ Pink conjunctiva
○ No anterior neck mass
○ No neck vein distentions
○ Normal Cardiac PE
○ Normal Lung PE
○ Normal Breast PE
○ Abdomen PE:
■ Flabby abdomen, McBurneys scar RLQ,
■ No tenderness
■ No masses
○ Pelvic PE
■ External genitalia: normal
■ Speculum: smooth cervix, copious dirty
white non foul discharge
■ IE:
● cervix soft, long closed, smooth,
● Uterus enlarge to AOG?
● No adnexal mass, tenderness
Clinical Impression G2P0 (0010) Early pregnancy, 11-12 wks AOG, Uncontrolled
Chronic Hypertension, Overt DM, Asymptomatic Bacteriuria,
Bacterial Vaginosis
Components of Complete Dx:
1. G_P_()
2. AOG (prioritize)
3. Other important
Diagnosis (Vaginosis,
Polyps, etc.)
4. Include history of CS
and indicate how many
times done
Ddx
Pacheck naman
Overt DM Asymptomatic Bacteriuria Chronic Hypertension
Signs & (+) UA: cloudy, bacteria +3, Usual BP: 140-150/ 90
Symptoms (+) FBS- Previous pus cells +1 (+) Losartan intake
labs
Physical BMI: 23.2 No dysuria BP: 140/90

Exam (Overweight)
Risk factors (+) Family Hx DM Preexisting DM (+) Family Hx of HTN
Rule in/out (+) Diagnose as (+) UA: cloudy, bacteria +3,

(+) Overt DM already pus cells +1
since FBS 200 (>126) (+) Copious dirty white non
foul discharge
Bacterial Vaginosis
- Consider: Copious dirty white vaginal non-foul discharge
Work - Up
Early Ultrasound - to establish pregnancy, location of the
pregnancy and viability, FHT, fetal anatomy
Congenital Anomaly Scan at 24-28 weeks (since DM px)
High risk pregnancy BPS at 26-28 weeks; Biometry every 4 weeks

starting at 28 weeks ata di ko sure
Final Diagnosis Management for DM:

● Medical Nutrition Therapy - Diabetic diet
Components of Complete Dx: ○ Daily caloric intake: 30-35 kcal/kg/day
● G_P_()
● Location (Pregnancy ○ 40% CHO, 20% CHON, 40% Fats
intrauterine; if twins add ○ Given as 3 meals and 3 snacks daily
chorionicity and ○ Refer to Nutritionist
amnionicity)
● AOG ○
● Other important ● Exercise
Diagnosis (Vaginosis, ○ ACOG: 30 mins or more of moderate exercise
Polyps, etc.) daily (brisk walking ganern, stretching)
● Include history of CS ○ Contraindications:
and indicate how many ■ Significant CVD or pulmonary disease
times done
■ Significant risk for preterm labor
■ Obstetrical complications
(preeclampsia, previa, anemia, IUGR)
● Request HBA1c
● Insulin
○ (if after 2 weeks Blood glucose is still elevated
or 3 abnormal values sa CBG monitoring in a
week)
● Self-monitoring of blood glucose
○ 7-point CBG (3 premeals, 3 postmeal, 1
bedtime)
○ Based on American Diabetes Association -
Goals: premeal <95
○ 1hr postmeal: <140
○ 2hr postmeal: <120
Management for HTN:

● Shift to Methyldopa 250mg tab BID/ Nifedipine
○ ACEi/ARBs teratogenic
● Give aspirin for prevention of pre-ecclampsia since 12
wks palang - best time to give after first Trimester
● Continue monitoring BP
● Ca supplementation 1.5-2 g/tab BID
● Modify diet? Kasi meat (steak)
Management for Asymptomatic Bacteriuria

● Penicillins and Cephalosporins
○ Nitrofurantoin 100mg BID x 7 days
■ Limit use to 2nd trimester to 32 weeks only due
to risk of hemolytic anemia & birth defects
○ Cefalexin 500 mg BID x 7 days
○ Cefuroxime 500 mg BID x 7 days
● Repeat urinalysis 1 week after treatment -wag ata urine CS?
Urinalysis na lang?? Urinalysis lang since doc TCL also hehe
tapos after next follow up?
○ Do monitoring (using urinalysis) every trimester
○ Because of 30% recurrence rate
Management Bacterial Vaginosis

● Metronidazole 500 mg tab BID for 7 days
Management
Prevention Aspirin 80 mg OD until 2 weeks before delivery or 36th week (for

prevention of preec)
Educate the patient on perineal
hygiene, vitamins, vaccination, Aspirin 150mg recommended
diet, exercise, etc. Start giving 12 weeks but before (ideal) 16 weeks
Follow up: after 4 weeks or when danger signs are present
FACILITATOR’S COMMENTS
Huy - HAHAHAHA gagi hahahahhaha

I HINDI WE hahahahhaahahha
NOTES FOR CARES
- Skip info not needed (MIDAS)

- If not contributory in any way, do not elicit.
- Palpate the cervix if it's smooth all over. Check all the sides.
- Recheck book references
- Prioritize you ancillaries
-
MUST KNOWS!!!
Fetal Heart Tones
● Ultrasound = 5 weeks
● Fetal echocardiography = 6-8 weeks
● Doppler = 10 weeks
● Stethoscope = 20 weeks
Medications:
First Trimester:
Folic acid supplement
● w/ prior history of neural tube defect (in order to prevent ntd in next pregnancy) = 4 mg 1 tab once
a day until end of first trimester
● w/o history = 0.4 mg or 400 micrograms 1 tab once a day until end of 1st trimester
Second Trimester:
Multivitamins
● Multivitamins (Clusivol OB) 1tab once a day
Iron supplement
● 1000 mg needed for pregnancy
○ 300 mg = actively transferred to the fetus and placenta
○ 500 mg = require 1.1 mg per 1 mL RBC of maternal hemoglobin expansion
○ 200 mg = obligatory losses primarily through GIT
● 6-7 mg/day
● Ferrous sulfate 325 mg/tab 1 tab once a day 30 minutes before meals
Calcium Supplement
● 1000mg requirement
● Calcium carbonate 500mg/tab 1 tab once a day before bedtime
For fetal lung maturity:

Corticosteroids:
● Betamethasone 12mg IM every 24 hours apart, 2 doses OR
● Dexamethasome 6mg IM every 12 hours apart, 4 doses
For Neuroprotection:
Magnesium sulfate MgSO4
IV:
● Loading dose: 4g slow IV infusion in 100mL saline solution over 15-20 minutes
● Maintenance dose: 1-2g/hr infusion pump for 24 hours or until birth, whichever comes first
IM:
● Loading dose: 4g as 20% solution by slow IV drip
● 5g as 50% solution IM each buttocks, every 4 hours
Check for (toxicity):

● Patellar reflex
● Urine output (should be >30mL/hr)
● Respiratory rate (normal: 12cpm)
Antidote:
● 10% Calcium gluconate 10-20mL by slow IV drip for 2-5 minutes
Tocolytics
Nifedipine
● Give immediately 30mg PO
● After 30 minutes, 20mg every 4-8 hours for 24 hours
● 10mg PO every 8 hours if contractions persist until 35-37 weeks
HPV Vaccine
● Ideally, should be administered before onset of sexual activity as this is intended as prophylaxis
and not for therapeutic purposes
● FDA-approved HPV vaccines
○ Cervarix
■ HPV16 and HPV18
■ Female ages 9-25 y/o
○ Gardasil
■ HPV16 and 18 as well as HPV6 and 11
■ Males and females ages 9-26 y/o
○ Gardasil 9
■ HPV 6, 11, 16, 18, 31, 33, 45, 52, 58
■ Females ages 9-26 and males ages 9-15
Laboratories to be requested during Prenatal Check-up:
● CBC
○ To determine hematologic status and rule out anemia
○ Normal hgb values
■ 1st trimester – 11 g/dL
■ 2nd trimester – 10.5 g/dL
■ 3rd trimester – 11 g/dL
○ There is physiologic anemia in pregnancy secondary to the increase in plasma volume
because there is “dilutional effect” on hgb and hct
○ Blood volume
■ Increased maternal blood volume = Hypervolemia
■ Hypervolemia associated with normal pregnancy averages to 40-45% increase
■ Function:
● Meet the metabolic demands of the enlarged uterus and its greatly
hypertrophied vascular system
● Provides abundant nutrients and elements to support the rapidly growing
fetus and placenta
● Protects the mother and fetus against the deleterious effects of impaired
venous return in the supine and erect positions
● Safeguards the mother against the adverse effects of
parturition-associated blood loss
■ Results from an increase in both plasma and erythrocytes
■ BUT more plasma than erythrocytes is usually added to the maternal circulation
■ Because of greater plasma augmentation, hgb concentration and hct decrease
slightly during pregnancy
■ The disproportion between the rates at which plasma and erythrocytes are added
to the maternal circulation is greatest during the second trimester
● Urinalysis
○ To evaluate for UTI and renal function
○ Proteinuria - preeclampsia
○ Physiology: Due to increased levels of progesterone, which is a potent relaxant, this
causes stasis of urine in the urinary bladder causing for the bladder to be a good niche of
bacterial infection
● ABO & Rh blood typing
○ To determine risk of isoimmunization
○ To screen for risk of Hemolytic Disease of the newborn and also to prepare in cases there
is a need for blood transfusion
● Syphilis and Hep B Surface Antigen
○ Serologic Test for Syphilis
■ RPR, VDRL
● To detect previous or current infection of syphilis
■ If (+), do Specific Treponemal tests
● FTA-ABS
● MHA-TP
○ HepB Surface Ag
■ If (+), do double glove delivery
■ Give baby Ig and HepB vaccine immediately after delivery
● FBS
○ Regardless of AOG, as long as first visit and no screening has been done yet,
immediately request for a fasting blood sugar
○ If patient has normal FBS and is low risk (no risk factors other than race), request for 75
g OGTT at 24-28 weeks AOG
■ If normal, screen again at 32 weeks
■ If abnormal at either 24-28 weeks or 32 weeks = manage as GDM
○ If patient has normal FBS but is high risk, immediately request for 75 g OGTT
■ If normal, screen again at 24-28 weeks
■ If still normal, screen again at 32 weeks
■ Once abnormal at either, manage as GDM
○ Consider abnormal 75 g OGTT if:
■ FBS >/= 92 mg/dL
■ 1st hour >/= 180 mg/dL
■ 2nd hour >/= 153 mg/dL
○ Glucose targets for pregnant women with GDM
■ Preprandial </= 95 mg/dL
■ 1st hour post prandial </= 140 mg/dL
■ 2nd hour post prandial </= 120 mg/dL
● Diabetic diet 30-35 kcal/kg/day (40% Carbs, 20% Protein, 40% Fats) - given as 3 meals
and 3 snacks daily
● Screening for Sexually Transmitted Infections such as

○ Hepatitis B via HBsAg
○ Syphilis Infection via RPR (Rapid Plasma Reagin) or VDRL (Venereal Disease
Research Lab test) - [FTA-ABS - confirmatory]
○ HIV Infection
● Transvaginal ultrasound may be performed to confirm the pregnancy. (viability
ultrasound) n cases wherein LMP of patient is not reliable, or there are suspicions about
the pregnancy, a
○ So at 9-10 weeks AOG, gestational sac, fetal pole (6 weeks) and fetal heart tone
(6 weeks) are expected.
○ Doppler - 10 weeks
○ Auscultation - 17 weeks
○ Accurately establish age of gestation with the use of crown rump length, to
confirm location of pregnancy (if with yolk sac - intrauterine) and determine
number of fetus.
● Follow up schedule:
○ After first PNCU to review laboratory results
○ Until 28 weeks AOG → 4 week intervals
○ By 28 weeks AOG → 2 week intervals
○ By 36 weeks AOG → 1 week intervals
● If with preeclampsia:
● CBC with platelet - Thrombocytopenia(plt <100,000/uL) is associated with worsening
disease and is itself a risk to the mother. A platelet count persistently less than 100,000
should be a consideration for delivery. Thrombocytopenia would also be a feature of
HELLP syndrome, and the presence of which would also be indicative of the need for
immediate delivery.
● HELLP syndrome - Hemolysis, elevated Liver enzymes, Low Platelet
● Confirmation of hemolysis warrants the need to request for LDH - this is confirmed if
LDH is Elevated (>600 U/L)
● A diagnosis of HELLP syndrome needs confirmation of hemolysis, either by LDH levels
(600U/L), blood film to look for fragmented red cells or total bilirubin >1.2 mg/dL;
● Elevated liver enzymes wherein we’d look for serum transaminase conc. >2x ULN (AST
or ALT >70 U/L)
● Another feature we’d look for is elevated serum creatinine- this is another feature of
severe pre-eclampsia and would point to acute kidney injury and decreasing GFR
● >1.1 mg/dL or doubling of baseline
● 24 hr-urine protein - to determine presence of proteinuria ≥300mg/24hr of urine protein
(NOT NECESSARY ANYMORE since presence pre-eclampsia is already established)
● Other possible tests to detect proteinuria: protein/creatinine ratio ≥0.3 (mg/mg) (30
mg/mmol) in a random urine specimen or dipstick ≥2+ if a quantitative measurement is
unavailable
● Due to disruption of the glomerular filtration barrier and altered tubular handling of
filtered proteins
● RMG: To distinguish whether gestational htn or preeclampsia (but since with dx of
preeclampsia already with severe features, not necessary anymore in this case)
●
●
ADMIT Admit to (OB ward, surgical ward, OR)

DIAGNOSIS Diagnosis
CONDITION Serious, guarded, critical, stable, etc
VITALS Check vitals every 15 mins, etc
ACTIVITY Bed rest, bed rest w/ bathroom privileges, crib and mother’s
arms, ad lib (at one’s pleasure), no restrictions, etc
NURSING ORDER For nurses to routinely do
DIET NPO, 1000 calorie, no salt, special diets, etc
IV FLUIDS Ex. D5 .2 NS + 20 mEq/L of KCL to run at 14 cc/hr
MEDICATIONS Medications should include name, dose, route and frequency.

Oxygen is included here.
LABS LABS
Ex. if HR <60 bpm
Natural Family Planning Methods:

Calendar method
● Based on the average cycle lengths of the women in the past 6-12 months
● Recommended only for women with regular cycles
● With irregular cycles - entail longer periods of abstinence (reason why they want to discontinue
NFP)
● For women regularly menstruating, subtract 14 from the cycle length, then subtract 5, then add 4
● For example: A woman’s menstruation cycle is 28 days. Her fertile days would be from the 9th
until the 18th day, while the remaining are infertile days (days 1-8 and days 19-28)
● Basis:
○ Subtracting 5 days from 14:
■ 2 days to allow possible early ovulation
■ 3 days is for the lifespan of the sperm
○ Adding 4 days to 14:
■ 2 days allowance for late ovulation
■ 2 days is for the estimated lifespan of the ovum
○ For women with irregular cycle; to get the fertile days:
■ Subtract 20 from the shortest cycle
■ Subtract 10 from the longest cycle
Cervical Mucus / Billings Method

● Requires a woman to observe the quality and quantity of her vaginal mucus discharge throughout
the cycle
● Advisable for: Women with irregular cycles (<26 or >32 days)
● Calendar method may not be that reliable for women with irregular cycles
● Observation is usually done at the end of the day or during the afternoon and not during at the
start of the day.
● Days after menstruation: DRY DAYS
○ Early, infertile days
○ characterized by G type of Mucus
○ Made up mostly of protein fibers, make it very hostile to the sperm
○ Does not facilitate the transport of sperm
○ Infertile type of mucus
○ Opaque and flaky
○ Sticky and not elastic
○ Lacks the slippery, lubricative quality of the fertile-type mucus
● As ovulation progresses: S type of Mucus
○ Fertile type of mucus (Spinnbarkeit)
○ Strings of raw egg white, smooth or slippery
○ Distinct wet and slippery feeling
○ Feeling of fullness, softness, and swelling in the tissues around the opening of the vagina
○ Provides the sperm cells with a protective envelope and facilitates its transport.
Saliva Ovulation Monitor

● Should be started at the end of menses
● No food or water for an hour
● Collection of saliva best under the tongue and placed on the microscope slide and allowed to dry
for 5-10 minutes
● Presence of ferning pattern: indicates fertilization (ovulation)
○ Don’t have intercourse if you see this if you don’t want to get pregnant
Basal Body Temperature

● BBT: waking temperature of the body before any activity
○ Hence you get temperature immediately upon waking up
● The lowest point/nadir in BBT is appreciable within 1-2 days before the LH surge
● Following ovulation, the BBT generally increases by 0.2 to 0.5 °C (biphasic pattern)
● The increase is due to the thermogenic effect of pregnanediol, a metabolite of progesterone,
which increases after ovulation and is secreted by the corpus luteum
● Chart daily BBT (from the first day of menstruation)
● Refrain from vaginal intercourse from the first day of menses until 3 days after the temperature
rise of 0.2 to 0.5 °C
Sympto-Thermal Method
● Requires identification of fertile and infertile days by combining BBT, cervical secretion
observations and other signs and symptoms of ovulation:
○ Abdominal pain/cramps
○ Breast tenderness
○ Changes in the position and firmness of the cervix
■ Remember, cervix:
● low, firm closed: during infertile period
● high, open, and soft: during fertile period
● The couple should refrain from intercourse when the woman senses secretions, until both the 4th
day after the peak cervical secretions and the 3rd full day after the rise in BBT
Lactational Amenorrhea Method

● This is also known as “breastfeeding as birth control”
● Three conditions that must be fulfilled for LAM method to be effective:
○ Lactational means exclusive breastfeeding
○ Amenorrhea means not having menstrual bleeding
■ Happens mainly due to the inhibition of pulsatile GnRH
○ Method is used when her baby is 6 months or less
■ Less effective if baby is older than 6 months
● Breast suckling inhibits pulsatile GnRH from the hypothalamus
○ Decreases LH (and FSH)
○ Suppresses development and release of viable follicle and ovum
● LAM is more effective if incorporated with the Billing’s method!
● Exclusive Breastfeeding
○ Must feed baby only breast milk
○ Intervals between feeding should not be longer than 4 hours during the day and 6 hours
at night
○ The baby should always be fed on demand
○ The more feedings and longer suckling periods = less chances of ovulation
○ Infant formula feeding may reduce the woman’s hormonal response
Standard Days/ Cycle Beads Method

● Applicable ONLY to women with 26-32 day cycle (NO MORE, NO LESS)
● May have unprotected intercourse on all other days
● Need not monitor temperature cervical secretions or any bodily symptoms
● Avoid intercourse from day 8-19 of the cycle (12 days)
● Each bead represents a day of her cycle
● Used more by women in the rural areas
● Things to remember:
○ On the first day of your menstruation, move the band to the red bead
○ Every morning, move the band to the next bead.
○ Always move the band in the same direction, from the narrow to wide end. Move the
band even on days when you have your menstruation
○ The day of your menstruation starts again, move the band to the RED bead. A new cycle
has started.
● On WHITE bead days, abstain from intercourse.
○ These are the days when you can get pregnant
● On BROWN bead days, you can have intercourse.
○ These are the days when you do not get pregnant.
Two-Day Method
● Check for presence of cervical secretions. Ideally every afternoon and / or evening
● As soon as secretions are observed, patient is considered fertile on that day and the day after
● Should avoid vaginal intercourse on these days
● Any secretions noted within the day or the day before points to a higher possibility of getting
pregnant if sexual contact ensue
● Start by asking if there are any secretions noted from yesterday and today, rather than the other
way around, for this method to be more successful.
AUG 24, 2021 9:00AM
OB eSGD
Case:
Script here.
NAME: Elsie AGE: 22 DATE: August 24, 2021
BIRTHPLACE: Manila CIVIL STATUS: Single but with Live In # OF YEARS RELIGION: Jehovah’s Witness
ADDRESS: Manila LIVE-IN: 1 year
OCCUPATION: Unemployed now, previously waitress EDUCATION: 2nd year college NATIONALITY: Filipino
CC: Follow-up prenatal (from last week)
● ONSET:
● LOCATION:
● DURATION:
● AGGRAVATING
● ASSOCIATED: Polyuria, polyphagia, polydipsia
● RELIEVING:
● TEMPORAL:
● SEVERITY:
● PREGNANCY TEST:
ASSOCIATED SYMPTOMS: SA ROS DAW ITO I-ASK!!

ALWAYS CHECK FOR DANGER SIGNS OF PREGNANCY!
1. HEADACHE (-)
SYMPTOM 2. BLURRING OF VISION (-)
● ONSET: 3. PROLONGED VOMITING (-) - naduduwal only but could be normal since hcg
● LOCATION: 4. FEVER (-)
● DURATION: 5. NONDEPENDENT EDEMA (-)
● CHARACTERISTICS: 6. HYPOGASTRIC PAIN (-)
● AGGRAVATING 7. DECREASED FETAL MOVEMENT - not applicable to current aog
● ASSOCIATED: 8. DYSURIA (-)
● RELIEVING 9. BLOODY VAGINAL DISCHARGE (-)
● TEMPORAL 10. WATERY VAGINAL DISCHARGE (-)
● SEVERITY
OBSTETRIC TOTAL PAST PREGNANCY: 1 FULL PREMATURE: ABORTION: ALIVE: OB SCORE:

HISTORY TERM 0 1 0
: G2P0 (0010)
0
1. 2018 8weeks, aborted
NOTES:
2. 2021 Current pregnancy
NOTES:
3.
NOTES:

MENARCHE 14 COITARCHE 21
INTERVAL Regular NO. OF SEXUAL 2, 3-4x a week

PARTNERS
DURATION 3-4d
POST-COITAL
AMOUNT 3-4 pads per day BLEEDING
SYMPTOMS DYSPAREUNIA (-)
CONTRACEPTIVES (-) OCP

USE
LMP June 28? Or 21?
OCCUPATION OF No job
PMP HUSBAND
AOG 8-9 weeks

EDC
● None
Please show solution here: GYNECOLOGIC HISTORY (if needed):

AOG ●
June 10
July 31
Aug 24
65/7 = 9wks 2/7 AOG?
EDC

SURGERIES, (-) DM (+) Maternal and (+) Paternal grandmothers
TRANSFUSION HTN (-)
OB & GYN CANCER

PROCEDURES
Others:
HOSPITALIZATION (-)
IMMUNIZATION COVID-19
(Childhood, Hepa B,
Covid)
COMORBIDS Not known
MEDICATIONS (-)
ALLERGIES (-)
SOCIAL HISTORY PREVIOUS PRENATAL CHECKUP

SMOKING (-) WHO
ALCOHOL Occasionally; stopped when got pregnant WHERE
COFFEE WHEN 1 week ago
DRUGS (-) FREQUENCY 1x
DIET Di malakas sa sweets, rice - tama lang RESULTS CBC - Normal

HGb 12
EXERCISE (-) HCT - 34
WBC - 4000
U/A: Normal;
+4 sugar in urine
FBS: 126 mg/dL baka mmol/L to (high if mmol/L) convert na

lang to mg/dL
mmoL ata yan i think (x18 to mg/dl = 126)
MEDICATIONS
REVIEW OF SYSTEMS:
GENERAL No DOB
No coughing
SKIN, HAIR, NAILS No chest pain
No fatigue
EYE
EAR
NOSE
MOUTH
CARDIO
PULMO
GASTROINTESTINAL
GENITOURINARY
HEMATOLOGY
NEUROLOGIC
ENDOCRINE
MUSCULOSKELETAL

○ MENTAL STATUS: AMBULATORY, NOT IN ○ INSPECTION OF EXTERNAL GENITALIA
DISTRESS, conscious, coherent ■ Unremarkable, inverted triangle
○ BODY HABITUS: ○ SPECULUM EXAM
○ WEIGHT: 130 lb ■ N/A
○ HEIGHT: 5’2 ○ INTERNAL EXAM
● VITALS SIGN: ■ CERVIX: soft, long, closed; no masses, no cervical motion tenderness
○ BP: 110/80 mmhg ■ UTERUS: compatible with AOG, no tenderness
○ HR: 92bpm ■ ADNEXA: unremarkable
○ RR: 18
■ CUL-DE-SAC
○ TEMP: 37
● ANTHROPOMETRIC DATA ■ BISHOP’S SCORE:
○ BMI: 23.8, Overweight ● Dilatation:
● SKIN, HAIR, NAILS: unremarkable ● Effacement:
● HEENT: unremarkable ● Consistency:
○ INSPECT: ● Position:
○ PALPATE: ● Station:
○ PERCUSS:
■ CLINICAL PELVIMETRY
○ AUSCULTATE:
● CARDIO: unremarkable ● RECTAL EXAM
○ INSPECT: ○ INSPECT:
○ PALPATE: ○ PALPATE:
○ AUSCULTATE: ● RECTOVAGINAL EXAM
● RESPIRATORY: unremarkable ○ PALPATE:
○ INSPECT:
○ PALPATE:
○ PERCUSS:
○ AUSCULTATE:
● BREAST: unremarkable
○ INSPECT:
○ PALPATE:
○ PERCUSS:
○ AUSCULTATE:
● ABDOMINAL
○ INSPECT: globular, no striae, no scars
○ AUSCULTATE:
○ PERCUSS:
○ PALPATE:
● EXTREMITIES normal
○ +2 pulses
SALIENT FEATURES
Script: We are presented with a 22 year old, G2P0(0010), Jehova’s witness, who comes in for a follow-up prenatal checkup.On speculum exam, the cervix was soft, long,
closed, no masses, uterus was compatible to AOG, no tenderness.
22 year old
Jehova’s witness
LMP: June 28 (last week of june) -> 8-9 weeks AOG
Last check up
- Urinalysis +4 sugar in Urine
- FBS: 7mmol/dL or 126 mg/dl
BMI - 23.8 - overweight
TENTATIVE DIAGNOSIS/ FINAL DIAGNOSIS: G2P0 (0010), PREGNANCY LOCATION, 8-9 weeks AGE OF GESTATION by LMP, Overt DM, Overweight

Last check up
- Urinalysis +4 sugar in Urine
- FBS: 7mmol/dL
BMI - 23.8 - overweight
1. Gestational DM Family history of DM, +4 sugar in urinalysis FBS >92 mg/dL but <126 mg/dL
2. Kidney Disease? glucosuria Need pa labs
3. Steroid use? hyperglycemia No intake of steroids?

Since FBS is 7mmol/d (126 mg/dl) = manage as OVERT DM Diet:

1. Medical Nutrition Therapy (Start on Diabetic Diet)
TVS ● Daily caloric intake:
● to establish AOG, location, viability and number, → Normal body weight: 30-35 kcal/kg/day
● Check for size baseline ultrasound; risk for growth
→ Obese: 24 kcal/kg/day
restriction or growth disorder (macrosomia)
○ Ideal in 1st trimester: unaffected by external factors? ● Ideal dietary composition for GDM (ACOG Recommendation):
→ Complex carbohydrates: 40% - 566kcal
HbA1c - glycosylated hemoglobin → Proteins: 20% - 283kcal
- To determine the blood glucose for the past 3 months → Fats: 40% -566kcal
- To know status pre-pregnancy ● Given as 3 meals and 3 snacks daily - to stabilize insulin release
- To know if treatment should be very aggressive already
- 6.5%: normal ● Refer the patient to Dietary and Nutrition Department for accurate advice
regarding nutrition
If normal Hba1c, no need to request for serum creatinine (want to ● Required kcal per day
economize)
→ Prepregnancy Weight (80kg x 24kcal/kg/day)
1. Obese- multiply by 24kcal/kg/day
2. Normal- multiply by 30-40kcal/kg/day
NUTRITION COMPUTATION
40% carbs
20% protein
40% fats 2. Exercise
- Perform 30minutes or more of moderate exercise daily (brisk walking)
- Daily chores (e.g. sweeping of the floor)
130lbs = 59kg
59*24 = 1418 kcal
3. Self monitoring of blood glucose (SMBG)
40%= 567 kcal for carbs and fats a. SMBG 4x a day
20%= 283.6 kcal for proteins - FBS 1x, Postprandial 3x
- If premeals - fasting
Carbs 4kcal/g - If post prandial - 1 hour from the first intake of food
Protein 4 kcal/g - Example: Patient started eating at 7 am and finished at 7:30 am,
Fat 9kgcal/g she should check at 8 am and not 8:30
- Daily Self-Monitoring of Blood Glucose (SMBG)
● Glucometer + Lancet
● Return after a week, and make sure to log the blood sugar ea
b. 7 point cbg: 2 weeks
Table 2. Frequency of Self-Monitoring of Blood Glucose

Current Therapy CBG Monitoring Frequency
GDM on Diet 7-point CBG monitoring

Treatment Alone Pre and 1-hr Post meals (6x) and then at
bedtime
GDM on Insulin 4-6x/day

Therapy Include preprandial values
Table 3. Self-Monitored Capillary Blood Glucose Goals (for pregnant with GDM)
Parameter Optimal Level
Fasting <95 mg/dL (5.3 mmol/L)
1-hr Postprandial glucose <140 mg/dL (7.8 mmol/L)
2-hr Postprandial glucose <120 mg/dL (6.7 mmol/L)
HbA1c <6%
able 3. Self-Monitored Capillary Blood Glucose Goals (OVERT DM)

Parameter Optimal Level
Pre-prandial, bedtime, overnight 60-99mg/dL
Peak post prandial 100-129mg/dL
HbA1c <6%
Prescription
Prenatal Supplements
● Folic acid 0.4 mg/tab 1 tablet once a day (first trimester)
● Multivitamins 1 tablet once a day
Follow up
● If after 2 weeks of diebetic diet, dm is still uncontrolled = insulin
○ Insulin Therapy (refer to endocrinologist)
■ Preferred first-line
■ Does not cross the placenta
■ Multiple daily doses of insulin and proper diet
■ Maintain CBG levels as close to normal
■ 1st trimester = 0.7-0.8U/kg/day
● Px: 41.3 units insulin per day
NOTES (ONLY WHEN ASKED)

TIMING AND ROUTE OF DELIVERY
○ Patients with well-controlled DM on diet with no complicating factor: delivered by
40 weeks AOG
○ Patients with poorly controlled DM: delivery at 37 weeks AOG
○ Diabetic patients may be delivered by outright CS if EFW >4000g
○ Elective CS at 39-40 weeks in patients with previous CS
○ Diabetes mellitus in itself is NOT an indication for CS
ADMIT
DIAGNOSIS
CONDITION
VITALS
ACTIVITY
NURSING ORDER
DIET
IV FLUIDS
MEDICATIONS
LABS
CALL HO
Topic
Facilitator LNR
Clerks Heredia, Jennifer & Legarda, Candice
Date 24 August 2021
HISTORY
Introduce, Get consent

● Magandang umaga, ako si clinical clerk <name>. Narito po ako para magsagawa ng hx taking. I-interviewhin ko lang kayo
at lahat ng ating mapag-uusapan ay mananatiling confidential, okay lang po ba sa inyo yun?
● Ano po ang buong pangalan mo? Ano po gusto mong itawag ko sainyo?
● Ilang taon na po?
● Saan po kayo ipinanganak at nakatira ngayon?
● Ano po ang inyong civil status?
● Ano po ang inyong trabaho at natapos pong pag-aaral?
● Ano po relihiyon?
● Filipino po ba?
General Data - Dize Name: ST

Age > 35 Age: 18
- risk factor for previa, abruptio Birthdate:
● Chief Complaint: Ano po Birthplace: Tondo, Manila
ang rason kung bakit po Address: Tondo
kayo nagpa-konsulta Marital Status: Single
ngayong araw? Occupation: Student (2nd year)
● If answer is related to Educational attainment:
pregnancy: ask if alam Religion: Catholic
niyang buntis siya and if nag Nationality: Filipino
pregnancy test na
● First time ninyo po ba Chief Complaint: Prenatal Check-Up (Follow up)
magpa-konsulta? Kung 2 wks ago yung prior;
hindi first time, tanungin UTZ: 26 weeks (2 weeks ago)
kung anong diagnostic at CBC urinalysis - normal
lab na pinagawa and
FBS - normal
result?
Meds:
- Iron
- Multivitamins
*pagkaask if alam kung buntis and yes, jump to LMP to know lang AOG - Bago pa po
tayo tumuloy, tanong ko lang po yung unang araw ng huling regla ninyo para lang po
malaman kung gaano na po katagal ang pagbubuntis ninyo.
LMP:
PPMP:
Compute for AOG:
Compute for EDD:

History of Present Comments:
Illness: Dize ● Number of prenatal check ups = 3
O: Kailan po ninyo unang Kasi no weight gain daw diba since kelan pa yun and interval ng check up?
napansin? ● Did not ask for sexual history =
D: Gaano katagal kapag dinudugo ○ Occupation
kayo? Tuloy-tuloy po ba ang ○ Number of sexual partners
pagdudugo? ● Pediatric patient
C: Masakit po ba? Marami po ba?
- Abruptio (painful) 2 weeks ago prenatal: no weight gain
A: May ginawa po ba kayo anung -
napansin ninyo yung pagdudugo
niyo? Symptom 1: hindi naggegain ng weight
A: May iba pa po ba kayo ● Onset:
nararamdaman bukod doon? ● Location:
Dysmenorrhea? Paghihilo? ● Duration:
Pamumutla? ● Character:
R: May ginagawa po ba kayo dito ● Aggravating:
para mawala? ● Alleviating:
S: If masakit, gaano kasakit? ● Relieving:
Pwede niyo po bang i-rate from ● Temporality:
1-10, 10 po ang pinakamasakit ● Severity:
May mga gamot po ba kayong Symptom 2:

iniinom ngayon? Mga iron? Folic ● Onset:
acid? Calcium? ● Location:
● Duration:
● Character:
● Aggravating:
● Alleviating:
● Relieving:
● Temporality:
● Severity:
Symptom 3:
● Onset:
● Location:
● Duration:
● Character:
● Aggravating:
● Alleviating:
● Relieving:
● Temporality:
● Severity:
Ask for Danger signs of pregnancy (according to doc LNR, part ng ROS)
N Meron po bang pagsakit ng ulo

N Panlalabo ng mata
N Hindi nawawalang pagsusuka
N Lagnat at panginginig ng katawan
N Pamamanas ng kamay at paa
N Sakit sa tiyan
● Ask for contractions if in labor or not
● Contractions signifying labor onset:
○ 3 spontaneous in >40 secs in 10 mins
○ 5 mins apart in 1 hour
○ >12 contractions in 1 hour
N Napansin po bang pagbabago sa paggalaw po ni baby? Nabawasan po ba?
N Sakit sa pag-ihi o hirap sa pag-ihi
N Meron po bang matubig o madugong lumalabas sa pwerta
● Blurring of vision, headache, convulsions, edema of hands and feet (preeclampsia)

● Fever, dysuria (UTI)
● Abdominal pain/hypogastric pain-> preterm labor and abortion
● Persistent nausea and vomiting-> GTD and multifetal pregnancy
● Watery / bloody discharge (threatened abortion, PPROM)
● Decreased fetal movement
● Uterine contractions
If patient came in for another prenatal check up, ask for previous check ups and
lab results
Focused ROS: Dize General Survey:
() Weight Changes
() Changes in appetite
() Malaise
() Sleep Changes
Breast:
Napapansin na pagbabago sa dibdib
() Masses
() Discharge
() Tenderness
() Nipple Changes
() Skin Changes: peau d’ orange, skin dimpling
Other systems (if pertinent)

Skin:
() Change in color
() Itchiness
() Hair changes (numipis, mabilis maputol)
HEENT:
Pulmonary:
() Dyspnea nahihirapan huminga
() Cough
() Wheezing
Cardiovascular:
() Chest Pain
() Easy fatigability
() Palpitations
() Leg swelling
Gastrointestinal:
() Changes in bowel habits
() Dysphagia
() Jaundice, pedal edema
Genitourinary:
() Changes in urine habits, frequency
() Urgency (hindi mapigilan ang ihi), volume
() Genitalia (masses, abnormal discharge)
MSK, Neuro, Vascular, Endocrine, Psych:

() Joint pain stiffness
() Joint swelling
() Muscle pain/cramps (pulikat)
() Weakness
() Syncope
() Memory loss
() Seizures (kombulsyon)
() Varicose veins (nakaumbok na ugat sa binti)
() Phlebitis/variceal pain, variceal swelling, leg claudication ()
Heat-cold intolerance
() Polydipsia
() Polyphagia
() Polyuria
() Abnormal bleeding/bruising/pallor
() Easy bruisability (pasa)
() Adenopathy (singit, kili-kili, leeg)
() Anxiety, depression, hallucinations, delusions, mood changes
(pagbabago sa emosyon, malungkutin, madali magalit)
() Normal pubic hair (pagbabago sa buhok sa ari)
OB-GYNE History Jen
Menstrual History: Menarche (kelan unang niregla) : 13

● Ilang taon po kayo nung una kayong niregla? Interval (pagitan ng una at huling regla): regular
● Regular po ba kayo nireregla? Kunyari ho April Duration (ilang araw nag reregla): 3-4 days
5 niregla kayo, kailan po ninyo ineexpect ang Amount (gaano kadaming napkin ang nagagamit, anong
susunod nyong regla? klaseng napkin po ang gamit? regular or yung night): regular
○ If irregular: mga gaano po katagal na pads
hindi kayo nireregla? Mga ilang Symptoms: dysmenorrhea? other symptoms? None
buwan po kayong hindi dinadatnan?
● Ilang araw po ito nagtatagal?
● Ilang pads po ang nagagamit nyo kada araw
ng regla? Ano po ang gamit nyo regular pads
o night pads? Napupuno po ba to?
● May nararamdaman po ba kayong sintomas
tuing wnagreregla? Tulad ng Sakit sa puson,
pagkahilo, pagsusuka?
Obstetrics History: G1P0 (0000)
● G: tanong ko lang po kung Ilan po ang Gravidity:

lahat ng pagbubuntis ninyo? Nakunan na Parity:
po ba kayo? Ilan po sa __ na sinabi niyo G1 (Year):
po kanina? ● BB boy/girl?
● Iisa lang ba ang ama sa lahat? ● AOG
○ Yung unang anak niyo, kailan po ● BW
pinanganak? ● NSD or C/S
○ Babae o lalaki? ○ Indication:
○ Naka-ilang buwan po siya nung ● Where: (Home/Hospital/Lying-in)
pinanganak? Husto po ba? ● Complications / Puerperium:
○ Naalala niyo po ba yung timbang ○ No complications
at haba po ni baby ○ GDM
pagkapanganak? ○ Preeclampsia
○ Normal po ba ang panganganak o ○ UTI
cesarean po? ○ Postpartum hemorrhage
■ If CS: Ano po ang rason? ○ Postpartum fever
○ May komplikasyon ba?
○ Saan kayo nanganak? Sino ang Gravidity:
nagpaanak - doctor po ba or Parity:
midwife? G1 (Year):
● BB boy/girl?
● AOG
● BW
● NSD or C/S
○ Indication:
● Where: (Home/Hospital/Lying-in):
● Complications / Puerperium:
○ No complications
○ GDM
○ Preeclampsia
○ UTI
○ Postpartum hemorrhage
○ Postpartum fever
Prenatal check up Who did and Where is Prenatal Care being done?
Nakapagprenatal check up na po ba
sila dati? Saan po? Pang ilan na po When is the first and last consult?
ito ngayon? Gaano po kayo kadalas
nagpapa-prenatal check up? Ano How frequent is the Prenatal Check-up?
pong mga lab tests na pinagawa sa
May nararamdaman ba kayo nung nag prenatal check up kayo?
inyo Ano pong resulta?
Laboratories, if there are any:
May mga gamot po ba kayong ● CBC, platelet count
iniinom ngayon? Mga iron? Folic ● Urinalysis
acid? Calcium? Multivitamins? ● FBS / OGTT
● TVS (when was it done)
● First prenatal usually: ● Blood typing
○ UTZ (gestational sac: ● HBsAg
5-6wks) ● VDRL / RPR
● HIV testing
○ Urinalysis
○ CBC, Blood type Medications:
○ FBS Part of the ‘History of Present Pregnancy’ if no complaint.
○ Hepa B This will be the last part of HPP.
○ VDRL A separate entry if (+) complaint
● 24wks & 32wks: OGTT Always ask for the ff information every PNCU (PreNatal Check Up):
Signs & symptoms experienced by the patient
Focus on “Danger Signals of Pregnancy”
Place of previous consult, weight, BP, FHT, etc
Medications prescribed:
Multivitamins/ Prenatal milk
● 1st trimester only (14 weeks) - 400 microgram/day orally
Iron supplement (Ferrous Sulfate)
● Dose: 30-60 mg daily Taken 30 mins before meals or at least 2
hrs after meals
● 1st trimester - 11 g/dl
● 2nd trimester - 10.5 g/dl
● 3rd trimester - 11 g/dl
Calcium
● Dose: 1.5 - 2 g/daily for prenatal care and prevents preeclampsia
Immunizations:
● Tetanus Toxoid
● Hepatitis B
● Influenza
● Pneumococcal
Gynecologic History: History of STI/STD?

● Nagkahistory po ba kayo ng History of discharge?
impeksiyon na naipapasa sa Vulvar itchiness?
pakikipagtalik?) Ulcerations?
● May discharge po ba Warts?
na lumalabas sa ari?) Pap smear with dates and results (last year, normal findings)?
● (Pangangati?)
● (Pagsusugat?)
● Warts?
● Pap smear with dates and
results (last year, normal
findings)?
Sexual History Pasensya na po medyo sensitibo pero kailangan lang pong itanong para
- Only ask if needed talaga since po sa kumpletong history at tamang diagnosis sainyo.
ayaw to tinatanong ni doc
mongon Coitarche: 16 y/o
- To know risk for cervical cancer No. sexual partner/s: 3
(sex at around teens and no Occupation of Partner/s: 2 students, 1 wala work, nakabuntis classmate
HPV vaccine) Regularity: (Gaano po kadalas) 2x/wk
• Important to ask the occupation of Associated symptoms: none (dyspareunia, bleeding):
partner none
o ex. call center agent: high risk for Date of last sexual contact:
STD
• Elicit promiscuity of patient (risk factor
for STDs like HIV) Type of contraceptive used: condom
Generic/brand name:
2 types of dyspareunia: Duration of use:
● Insertional (vaginal pathology) - Reason for choice
vaginitis Satisfaction with method:
● Terminal (parang may Effectiveness of method:
binabangga - uterosacrals, Undesirable side effect:
posterior fornix) - implants If already stopped, Date?
Reason for discontinuance of the method:
Ask history of partner and occupation!!

Contraceptive History Know promiscuity of patient
Past Medical History: Dfize Comorbidities:

●
● Comorbidities: May ibang sakit po ba
kayo tulad ng altapresyon, diabetes, Past Hospitalizations:
asthma, TB, sakit sa thyroid, PCOS, ●
Stroke, Cancer, Gout etc.
○ PCOS: irregular po ba ang regla Past Surgeries:
ninyo kasama po ng pagkakaroon ●
ng buhok sa mga hindi naman
pong karaniwang tinutubuan nito Injuries/Accidents:
o kaya pagdami po ng mga ●
pimples at pagtaba, (at kung
sakali po nagrequest po ba ng Blood transfusion:
ultrasound para po sa obaryo ●
ninyo?)
○ Gout: masakit po ba ang Immunizations:
kasukasuan? ● No flu
○ Naaalala nyo po ba kailan kayo ● Complete covid
nadiagnose? Kahit taon lang po?
○ ALTAPRESYON: ask most recent bp,
Current Medications/Supplements:
usual bp and highest bp
○ DIABETES: ask if controlled ang blood ● Generic Name:
sugar or may iniinom na gamot? ● Brand:
● Past hospitalizations/surgeries: ● Dose:
Naospital na po ba dati? Naoperahan na ● OD/BID:
po ba dati?
○ Always ask year, reason for Allergies:
operation, any complication? ●
● Injuries/ Accidents: May mga accidents
po ba dati na nainjure kayo?
● Blood transfusion: Nasalinan na po ba
ng dugo?
● Immunizations: Nabakunahan na po ba
laban sa cervical cancer o HPV vaccine?
Nagkaroon na po ba ng flu vaccine?
● Current Medications/Supplements: May
mga gamot po ba kayong iniinom
ngayon? Para saan po ito? Generic
name, brand, dose? Self-prescribed/
doctor prescribed? [If HTN or DM, ask if
controlled BP or blood sugar level]
● Allergies: Meron po bang allergies sa
pagkain o gamot? Sa pain relievers po
wala?
● Ask for any ancillaries if available like TVS
or labs
○ If >40, nagpamammography na
po ba kayo? Ano po ang resulta?
○ Ask for pap smear, ano po ang
resulta?
○ Self breast exam? May nakapa
po bang bukol?
Family History: Dize Father:

DM, HTN, CA (breast, cervical, endometrial, Lola DM
ovarial), asthma, heart diseases Cousin Colon CA
PCOS and other Mother: HTN
genetic gyne disease Siblings:
Other family members:
Personal and Social History: Dize
● Ano po ang usual na sangkap ng

meal/pagkain nyo? (ex: kanin,
manok/baboy/beef, gulay)
● Nag eexercise po ba kayo? Ano po yung Diet: usual food in the house
pinakaphysical activity niyo? Activity Level/Exercise:
● Naninigarilyo po ba kayo? Kailan po Smoking: yes 5x/day stopped, 16 years old
nagsimula? Ilang packs po sa isang araw? Alcohol Intake: occasionally before nalaman na buntis
Hanggang ngayon po ba? Bakit po kayo Illicit drug use (pinagbabawal na droga):
tumigil? Environmental exposures: none viral infections
● Umiinom po ba kayo ng alak? Palagi po ba? No travel, exposure to COVID:
Tuwing kailan po? Gaano po kadami?
Stress - with pandemic, school
● Yung sunod ko pong katanungan mejo
sensitive po, pero kailangan po namin ang
honest na kasagutan nyo. Gumagamit po ba Headssss since adolescent
ng ipinagbabawal na gamot?
PHYSICAL EXAM
General Survey Pulmo Abdominal
Vital Signs Cardio Pelvic (Inspection, Speculum, IE)
Anthropometrics Breast Extremities
HEENT
General Survey Jen The patient is conscious, coherent.

Is she ambulatory? yes
Vital Signs Jen BP:

● Pre-pregnancy: 110/80
Height important din to ● Usual: 110/80
know baka small yung ● Current: 1
px HR: 85
RR: 18
Temp: 36.5
Sp. O2 (not part of PE)

Anthropometric Data Height: 5’4”
Jen
Weight
● Pre-preg: 100lbs
● Current: 105lbs
BMI
● Pre-preg: 17.2
● Current: 18.0 underweight
HEENT Jen ● Pink palpebral conjunctiva

● Anicteric sclerae
● Gum bleeding? No
● Neck masses? No
Lungs Jen INSPECTION

Symmetrical chest expansion
Inspection: No deformities (pectus excavatum
Use of accessory muscle
AUSCULTATION
Clear breath sounds
Chest Jen ● Adynamic Precordium

● No murmurs
Breast Jen Before starting I would ask for consent

If pertinent?
Inspection
• Wash hands Any gross abnormality on the breast?
• Introduce yourself (Asymmetry) symmetrial
• Confirm patient details Before assuming asymmetry, always ask if it is always have been asymmetrical
• Explain Examination The dominant side usually appear larger than the other side
• Gain Consent Swelling none
• Ensure a Masses none
chaperone is Skin Changes none
present o Male Nipple Changes
gynecologist - Pressing into hips
should be (Contraction of Pectoralis Major)
accompanied by a Hands behind head )
female assistant o Push elbows back and lean forward (will exacerbate skin dimpling)
• Expose patient
• After examination: Palpation
o Thank Patient Asses:
o Wash Hands Asymmetry?
• Self-breast exam is Swelling?
recommended once a Mass?
month after Location
menstruation Size/Borders
o Best time: 1 week after Consistency
menstruation Fluctuance
▪ Hormone has less Fixation
effect in the breast
o While woman is
taking a bath •
Clinical (done by the
physician) breast
exam once a year
or every 2 years
together with pap
smear
• OB-GYN - only
perform diagnostic o If
biopsy is needed, refer
to surgeon • High risk
for breast CA = request
mammography at age
40
• Not high risk = request
• Non-palpable lesions
can be
detected in
mammography
Abdominal Dize <16 weeks

Inspection: Flat or globular? Presence of striae, scars?
Auscultation: bowel sounds: normoactive?
Palpation: Direct/Rebound tenderness?
16-28 weeks
Inspection: globular?no striae, scars?
(unahin FH after inspection accd to LNR recording)
Fundic Height: 25 cm
Since the patient is _____ weeks AOG, is the fundic height at the level of
??? (do at 16-18 weeks from superior border of pubic symphysis to
fundus)
○ 12-14 weeks: fundus at the level of the symphysis pubis
○ 16 weeks: midway between the symphysis pubis and umbilicus
○ 20 weeks: at the level of the umbilicus
Auscultation: bowel sounds: normoactive yes
● Fetal heart tone via stethoscope only at 18 weeks
● 150 bpm
Palpation: no Direct/Rebound tenderness no
28 weeks
1. Inspection: Flat or globular? Presence of striae, scars?
2. Fundic Height = 25 cm EFW= _____kg
3. Auscultation: FHT= 150 bpm located on the ______________, note for
regularity.
4. Palpation: Direct/Rebound tenderness?
5. Leopold's Maneuver (start at 28 weeks)
a. LM1 = breech
b. LM2 = fetal back left
c. LM3 = cephalic
d. LM4 = cephalic prominence right
LM1 (Fundal Grip) breech

Determines what fetal pole occupies the fundus
- Cephalic presentation: large nodular body representing the buttocks or
lower extremities
- Breech presentation: hard, freely moveable and ballotable part representing
the head
- Shoulder presentation/ Transverse lie: empty
LM2 (Umbilical Grip) - fetal back left

Determines on which maternal side is the fetal back
- Fetal back: resistant convex structure
- Fetal small parts: numerous nodulations
LM3 (Pawlik’s Grip) - cephalic

Determines what fetal part lies over the pelvic inlet
- Head engaged: feel shoulder, fixed, knob-like
- Head not engaged: feel round, ballotable mass
- Cephalic presentation is not engaged: movable, round, hard body palpated
- If lower pole of fetus is engaged, head is fixed.
LM4 (Pelvic Grip) on right

Determines on which side is the cephalic prominence
- Opposite side as back → head flexed
- Same side as back → head extended
Engaged or not?
- Engaged: hands are parallel and does not meet
- Not engaged: hands converge
Pelvic Exam Dize First, ask the patient to void
IE - don’t do if bleeding External Genitalia; Inspect the Vulva

in the second half of ● Lesions
pregnancy!! ● Scars
Ask to empty bladder ● Erythema
● Discharge
Introduce yourself ● *Pubic Hair Distribution
Confirm patient details - inverted triangle pattern
o Patient’s name and
date of birth Inquire
about possible
pregnancy Check
patient’s understanding
of the procedure
Explain the examination
o Explain that light
vaginal bleeding or
spotting may occur
Ensure a chaperone is
present
o For male physicians,
always ask a female
colleague
to accompany you
Gain consent
Always ask to empty
the bladder prior to the
procedure
o Except on cases on
introital mass,
prolapse and
complain of incontinence
Gather the
equipment to be
used o Gloves
o Speculum
o Lubricant
o Sample Pot
o Endocervical brush
(sterile spatula and
popsicle stick can also
be
used)
Speculum Exam Dize
● Inspect the Cervix:
● Speculum Exam ○ Color: is it violaceous, smooth?
- Hold the handle ○ Discharge (amount, color, description): minimal whitish
of the speculum ○ Gross lesions?
with your ○ Shape of external os:
dominant hand, - parous cervical os (fish mouth) or
and - nulliparous cervical os (circular)
● open the labia
minora with the
other one (use
thumb and 5th
finger). Insert the
CLOSED
speculum gently,
sideways at first,
then slowly rotate
to the normal
position, then
gently open the
speculum. Inspect
the cervix.
INTERNAL CERVIX:
EXAMINATION (IE) Dize ● Soft, long, closed
● (-) Cervical motion tenderness
Don’t do if the vaginal ● Bishop Scoring (if in labor)
bleeding is on the ○ Dilatation:
second half of ○ Effacement:
pregnancy ○ Consistency:
○ Position:
○ Station:
Bimanual Exam
■ Score of </=4: unfavorable cervix and maybe an indication for
cervical ripening
■ Score of >/=9: high likelihood for successful induction
UTERUS:
● Enlarged to how many months / AOG (don’t just ask if enlarged, specifically ask
if enlarged to how many months)
● Movable
● Tenderness
● Example: uterus is enlarged to 4 months size, boggy, with slight ballooning of the
isthmic portion Ovaries adnexa cannot be assessed
ADNEXAL: Cannot be if > 14-16 weeks AOG

● No adnexal masses nor tenderness
○ If there’s mass: borders, size, movable?
● Adnexa cannot be assessed?
● Tenderness of cul de sac
CLINICAL PELVIMETRY (if in labor)

● INLET:
○ Diagonal conjugate ≥11.5 cm
○ Sacral promontory not accessible
○ Engaged head
○ Muller hillis Maneuver
● MIDPELVIS:
○ ischial spine not prominent
○ curved sacrum
○ walls divergent
● OUTLET:
○ wide pubic arch,
○ fist can fit the bituberous diameter (> 8 cm)
Rectal Exam Inspection

• A rectal examination • Rashes
is primarily done if the • Hemorrhoids
patient is a virgin or • Anal Fissure
has no sexual history. • Bleeding
Do not do • Fistulae
vaginal exam given • Abscesses
those
indications Palpation
• Introduce yourself ● Lubricate the finger
• Confirm patient ○ Use the Index Finger
details ● Insert the finger gently into the anal canal
• Explain the procedure
○ Assure that it
will be a quick
examination
○ Assure that the
patient may opt to
stop the procedure if
there is any
discomfort
• Gain Consent
• Ensure a
chaperone is
present (especially
if Male
Gynecologist)
• Gather the Equipment ● Rotate the finger 360 degrees to assess the anal canal
○ Gloves ● Palpate for the following:
○ Apron ○ Cervix
○ Lubricant ○ Size of the Uterus
○ Paper Towels ○ Adnexal area
• Wash hands ▪ Ideally, there is nothing to feel or palpate in the
thoroughly adnexal area
• Wear apron and ▪ Any mass that can be palpated in the area is
gloves considered a suspicious abnormality
• Position the patient ● Shift to the right side and left side
○ Males = lateral ● Assess the anal sphincter tone
recumbent ○ Ask the patient to squeeze the finger
position ● In rectal/rectovaginal exam, you can palpate for tender
○ Ideally for a nodularities in the uterosacral ligaments (endometriosis).
Gynecologist, the
dorsal lithotomy
position should be
maintained
○ After IE, you can
insert one finger into
the rectum unless you
are going to do a
rectovaginal exam
meaning index finger
in the vagina, third
finger in the rectum
• Expose the patient
• Inspection
• Palpation
• Withdraw and
inspect finger and
assess
○ Blood
○ Stool
○ Mucus
• Wipe away
excess lubricant •
Cover the patient
• Dispose the
equipment into a
clinical waste bin
• Wash Hands
• Summarize the
findings
• Do a full abdominal
examination for
further assessment
Rectovaginal Exam Palpation

Palpate the tissue in between the rectum and the vagina (rectouterine
● From the pelvic pouch of douglas)
exam, gently slip the Nodularity
middle finger to the Tenderness
rectum while the Masses
index finger For the rectal finger, palpate the integrity of the rectal mucosa and
remain in the presence of mass.
vagina Rectal Mass
● Insert the finger in
the full length of the
vagina . COMMENTS:
● Palpate the tissue in ● IE - do not ask already if uterus is enlarged to AOG since fundic height was given
between the rectum
and the vagina
(rectouterine pouch
of douglas) ○
Palpate for
nodularity,
tenderness, and
masses
● For the rectal
finger, palpate the
integrity of the rectal
mucosa and
presence of mass.
● Example:
○ A patient with an
enlarged ovary
wherein we cannot
examine
properly by vaginal
exam
● Rectovaginal exam
may be
warranted if there are
inconclusive results
from the vaginal exam
● Index finger is
inserted into the
vagina, and the
Middle
finger is inserted
into the rectum (anal
opening)
● Generally:
○ Vaginal Exam,
Rectovaginal Exam
and Rectal exam will
not do harm in a
pregnant patient
● Enterocele can be
identified in patients
with pelvic organ
prolapse.
● Why do we need to
end a
gynecological exam
with a vaginal exam
(not appreciated
enough with IE)
○ You can sweep your
finger at the back of
the uterus, to palpate
uterosacral and cul
de sac area
○ For ovarian cysts
that is toward the
back
▪ unlike in lateral
ovarian cyst that is
appreciated on IE
Extremities Dize Full and equal pulses?
SALIENT FEATURES - Jen
SUBJECTIVE FINDINGS OBJECTIVE FINDINGS
18 yr old primigravid, single, student who came for a follow up Pre-pregnancy: 100lbs BMI: 17.2
prenatal check up with last prenatal check up 2 weeks ago which Current: 105lbs BMI: 18 Underweight
revealed 26 weeks AOG with normal CBC and urinalysis FH = 25cm (28AOG) FH < AOG
She was asked to come back since she is not gaining weight
Vital signs were all normal except: Underweight
Fx: DM grandmother, cousin Colon Ca, mother HTN Systemic pe: unremarkable except:
Abdomen: globular
FH: 25 cm (28 AOG) FH<AOG not compatible
Risk factors: with AOG
● 5 sticks a day, now still smokes occasionally even while FHT: 150 bpm (normal)
pregnant (start 16 years old) ilang pack year hx No (pertinent negatives) ___________
● Used to drink alcohol but stopped when she became External genitalia: inverted triangle pattern; no lesions
pregnant Speculum exam revealed: cervix violaceous, minimal whitish
● Stressed due to pregnancy and due to COVID discharge
● Stressed due to family not supportive of pregnancy? Internal examination showed:
CERVIX:
3 sexual partners, with sexual activity 2x a week ○ Soft, long, closed
○ (-) Cervical motion tenderness
Symptom:
●
PE:
Labs:
CLINICAL IMPRESSION: - Jen

G1 P0 Pregnancy uterine at 28 weeks AOG by UTZ, Cephalic Presentation, Probable Fetal growth restriction, Underweight
*Only input data here during ESGD!

Signs and Symptoms
Physical examination
Diagnostic/ ancillary (make Uterine fundic height

sure to request for labs that - Serial measurement
will be cost-effective) - 18-30wks AOG correlates w FH
Continue Fetal movement counting
Fetal surveillance methods for IUGR: NST, BPS. Dopper utz
Fetal biometry to estimate the weight

- Abdominal circumference
- Most frequently abnormal with fetal-growth restriction because soft tissue
predominates in this dimension
- Femur length
- Head circumference
AF volume measurements
- Reflection of uteroplacental blood flow
Doppler velocimetry
- Uterine a.
- Usd to predict IUGR
- Umbilical a.
- Monitor
- IUGR = absent or reversed end diastolic flow
Definitive diagnosis cannot be made until delivery
1ST TRIMESTER
● TVS - viability, age of gestation (CRL), location, number
● Fetal biometry (can start at 13 weeks) - if thinking of IUGR
○ Biparietal diameter, femur length, abdominal circumference, head circumference
2ND TRIMESTER
● Congenital anomaly scan (24-26 weeks) - if with risk factors (e.g. genetic disease, illicit
drug intake)
● Biophysical profile score (28 weeks) - NST, FBM, FM, FT, AFV (10/10)
○ Fetal tone
○ Fetal movement (16-18: multigravida; 18-20: primi)
■ 10x every 2 hours
○ Fetal breathing
○ Nonstress test - to make it 10/10 (not done unless 1 in BPS is abnormal since
expensive)
■ Reactive fhr: 2 or more episodes of acceleration of >15 bmp and of >15s
associated with FM within 20 mins
■ To check fetal condition
○ Amniotic fluid level : chronic
■ Single: <2cm oligo, >8cm poly
■ AFI <5cm oligo >25 cm poly
● Doppler velocimetry - for IUGR, GDM or preeclampsia
○ Uterine artery notching (20 weeks) - preeclampsia and IUGR
○ Umbilical artery - uteroplacental blood flow and IUGR
○ Middle cerebral - fetal anemia
■ Normalized value - no fetal compensatory mechanism under hypoxia
■ Decreased resistance in compensatory state
3RD TRIMESTER
● Fetal Biometry
● If in labor : Labor Admission Test
○ Check for baseline FHR, variability, and accelerations, decelerations
○ Category 1 / Normal Tracing - No intervention necessary; proceed with NSD?
○ Category 2 / Suspicious Tracing - Indeterminate; correct reversible causes if
identified, close monitoring
○ Category 3 / Pathologic Tracing - Immediate action correct reversible causes;
resuscitative measures
■ Place patient on lateral decubitus position
■ Oxygen support - not more than 1 hr
■ Discontinue uterine stimulation
■ Treat maternal hypotension; give IV fluid bolus of 200cc
* If need surgery, don't forget to request for cbc, blood chem, pt/ptt etc. and COVID-19 RT-PCR
swab test!
FBS / OGTT - screen for overt DM / GDM

Normal / Cut-Off Patient Interpret
Normal FBS: < 92 mg/dl (5.1 mmol/L)
GDM FBS: ≥92 mg/dl but <126 mg/dl

OGTT: 1-hr ≥180 mg/dl; 2-hr ≥153 mg/dl
Overt DM FBS: ≥126 mg/dl (7.9 mmol/L)

RBG: 200 mg/dl (11.1 mmol/L)
HbA1c: 6.5%
2-hr: 200 mg/dl (11.1 mmol/L)
Urinalysis - screen for asymptomatic bacteriuria

RBC
WBC
Bacteria
Protein
CBC with Platelet Count - screen for IDA, check for leukocytosis
Hgb 1st Trimester = 11 g/dL

2nd Trimester = 10.5 g/dL
3rd Trimester = 11 g/dL
Hct 1st Trimester = 31-41%

2nd Trimester = 30-39%
3rd Trimester = 28-40%
WBC 1st trimester = 5.7-13.6

2nd trimester = 5.6-14.8
3rd trimester = 5.9-16
Predominant
WBC
Blood type with Rh: screening for ABO/Rh incompatibility; also for future possible transfusions
Pap Smear: screening for cervical cancer (if with hx of sexual intercourse for the last 3 years)
Hbsag: 3rd trimester
If high risk only (multiple partners):
- RPR/VDRL: screening for syphilis
- HIV test: screening for HIV
Transvaginal Sonography: to confirm pregnancy; and obtain sonographic age of gestation
● First trimester sonography would include aging of the fetus especially in the first trimester
via the crown rump length (CRL).
● (Example of a report: TVS showed a single live intrauterine pregnancy, 12-13 weeks AOG
by CRL, with good cardiac activity.)
Transabdominal sonography:
- Gestational sac: - 4-5 weeks
- Yolk sac: 5 weeks
For AOG:
- CRL- 12 weeks and below
- Fetal biometry - >13 wks (14-26 weeks) (biparietal diameter, femur length, abdominal
circumference, head circumference)
- FH: 16-30 +-2 weeks AOG accuracy: measure from superior border of symphysis pubis to
fundus
Congenital anomaly scan- 18-24 weeks up to 28 weeks (depends lang if may risk factor)
Antepartum surveillance: 26-28 wks
- BPS
- Fetal tone
- Fetal movement (16-18: multigravida; 18-20: primi)
- 10x every 2 hours
- Fetal breathing
- Nonstress test - to make it 10/10 (not done unless 1 in BPS is abnormal since
expensive)
- Reactive fhr: 2 or more episodes of acceleration of >15 bmp and of >15s
- To check fetal condition
- Amniotic fluid level : chronic
- Single: <2cm oligo, >8cm poly
- AFI <5cm oligo >25 cm poly
- Contraction
- 3 spontaneous in >40secs in 10mins
- Doppler velocimetry (only if at risk)
- Middle Cerebral: fetal anemia
- Umbilical artery: uteroplacental blood flow
- Uterine Artery: preeclampsia and IUGR
Management (Include Management Goals:

therapeutic and preventive;
management goals;if kaya
gawing specific like dose etc) Management:
At 28 weeks, give corticosteroids for pulmonary maturation

Antenatal surveillance
As long as there is interval fetal growth and fetal surveillance test results are normal, pregnancy is
allowed to continue, reassess fetal growth every 3-4 weeks
Preventive:
Surveillance/Monitoring (if applicable):
Possible causes of incompatible fundic height: placental spillage, genetically small baby
Based on Chief Complaint: Vaginal Discharge
*Make another table if di kasya ddx here
Differentials Fetal Growth Restriction SGA (Genetically small) Oligohydramnios
Signs and Symptoms RF: Inquire about height of father Cause a decrease in fundic
- Smoker and alcoholic height
drinker pre pregnancy Low maternal weight gain
- Stressed due to family
not supportive of Causes:
pregnancy, COVID - PPROM
- Birth defects (i.e.
urinary tract ->
Patient not gaining weight decreased excretion of
despite her on 28wk AOG fetal urine)
(should be 1lb/wk in 2nd and - Maternal factors (i.e.
3rd trimester) HTN, DM,
preeclampsia)
- Maternal smoking and
alcohol does not
appear to affect either
amniotic fluid volume
or fetal urine output
Physical examination BMI 18, Underweight

FH 25cm not compatible w
28wk AOG
Reason for R/o? Physical findings of inutero No passage of fluid

malnourishment
Diagnostic/ ancillary
Management
Admitting Order (using ADMIT mnemonic, include dosage)
A Admit to the service of Obstetrics and Gynecology under Dr. _______
D GxPx (xxxx), Pregnancy, uterine at ___ weeks AOG, Placenta Previa
D Diet as tolerated / NPO (if considering surgery)
A Modified bed rest / bed rest with bathroom privileges
M Monitor BP, HR, RR, SpO2 q4h then record
I Monitor input and output every shift and record
I Request for: CBC, blood-typing, antibody screen, cross-match
T Give Betamethasone 12 mg IM every 24 hours for 2 doses, or Dexamethasone 6 mg IM

every 12 hours for 4 doses (if <34 weeks)
Don’t repeat the ones mentioned earlier
Concerned more of FHT, FH, Leopold’s maneuvers, in 32 weeks AOG than the bowel sounds Give first impression
and formulate plan of treatment
Do not recommend ancillaries the patient does not need. And be specific in requesting.
Why placenta previa?

Painless vaginal bleeding in the second half of pregnancy
No tetanic contractions as seen in abruptio placenta
Can occur in primis
Risk factors for Abruptio placenta:

Age
Multiparity
CS delivery
HPN
Prior Abruptio
Trauma or accident
What in history makes you say she may have a concomitant accreta? What puts her at risk?
Previous CS (nullipara ung patient)
Prior history of trauma to endometrium (hx of curettage, hysteroscopy of submucous myoma) **but this patient no
previous surgeries or trauma
If no bleeding in 36-37 weeks will you still do cesarean?
General comments:
● Be more focused
● Review dosage of medications
● Always base differentials on what the patient has
● Ideally, 3rd trimester bleeding and thinking of Placenta Previa refrain from doing IE and go for ultrasound
● Missed in hx:
- No partner hx
- No hx of how many prenatal check ups
- Pediatric patient
- Environmental
- People in house, where they live etc
- Was given fundic height, why ask again uterus enlarged
- Try to be cohesive/ consistent
○ History of contact the night before prior to bleeding (since vaginal wall and cervix edematous and
swollen in pregnancy → easily traumatized)
NOTES FOR CARES

-
Topic
Facilitator CRO
Clerks Ilano, Ilaya
Date 24 August 20218
HISTORY

● Magandang umaga, ako si clinical clerk <name>. Narito po ako para magsagawa ng hx taking. I-interviewhin ko
lang kayo at lahat ng ating mapag-uusapan ay mananatiling confidential, okay lang po ba sa inyo yun? Simulan
ko na po.
● Ilang taon na po at kailan po ang inyong birthday?
● Saan po kayo pinanganak at nakatira ngayon?
General Data Name: Anna Santos “Anna”

Age: 25
Birthdate: March 4
Chief Complaint: Chief Complaint: Ano Birthplace: QC
po ang rason kung bakit po kayo Address: QC
nagpa-konsulta ngayong araw? Marital Status: Married, 1 year
- Nag-pregnancy test na po ba sila? Ano
pong resulta? Nationality: Filipino
- Matanong ko lang din po, kelan po ang Religion: Catholic
unang araw ng huling regla nila? Tapos Occupation: Housewife
hanggang anong araw po yon? Regular
naman po sila?
- First time niyo po bang magpaconsulta
ngayon? Ano pong mga tests ang
pinaggawa?
Normal naman po mga results?
First time niyo po ba magbuntis? CC: “Sumasakit ang tiyan” abdominal pain
● First prenatal usually:

○ UTZ (gestational sac:
5-6wks)
○ Urinalysis
○ CBC, Blood type
○ FBS
○ Hepa B
○ VDRL
○ Pap smear
History of Present
Illness: O: 3-4 days ago
O: Kailan po ninyo unang napansin? L: Initially, umiikot → More on the right
D: Gaano katagal kapag dinudugo D:
kayo? Tuloy-tuloy po ba ang C: Pinipiga, mas masakit sa bandang ilalim
pagdudugo? A: Vomiting, dec in appetite, no headache, warm to touch, no
C: Masakit po ba? Marami po ba? dysuria
- Abruptio (painful) ● Vomiting - 4 days ago: 3-4x/day → now: 5-6x
A: May ginawa po ba kayo anung A:
napansin ninyo yung sintomas ninyo? R: No medications taken
A: May iba pa po ba kayo T: Intermittent → now continuous
nararamdaman bukod doon? S: 4 days ago 4/10; now 8/10
Dysmenorrhea? Masakit ang ulo?
Pamumutla? Masakit ang ihi (pagdaloy
ng ihi)? Lagnat? Chills? Panlalabo ng (+) pregnancy test (2 days ago)
paningin? Pagsusuka at paghihilo? First consult
Nararandam naman po yung paggalaw
ng bata ninyo sa tiyan? Kamusta No medications
naman po yung pag galaw - parang
nabawasan ho ba o pareho pa rin?
R: May ginagawa po ba kayo dito para
mawala?
S: If masakit, gaano kasakit?
May mga gamot po ba kayong iniinom

ngayon? Mga iron? Folic acid?
Calcium?
● Blurring of vision, headache, Ask for Danger signs of pregnancy

convulsions, edema of hands and
feet (preeclampsia) No Meron po bang pagsakit ng ulo
○ After 20wks AOG Yes or No Panlalabo ng mata
Yes Hindi nawawalang pagsusuka
○ anytime
● Abdominal pain/hypogastric pain-> Yes o Lagnat at panginginig ng katawan
preterm labor and abortion Yes or No Pamamanas ng kamay at paa
○ anytime Yes or No Sakit sa tiyan or nararamdamang contractions
● Persistent nausea and vomiting-> Yes or No Napansin po bang pagbabago sa paggalaw po ni
GTD and multifetal pregnancy baby? Nabawasan po ba?
○ 3 months AOG ● Ilang fetal movements po ba kada oras? Di nabibilang,
● Watery / bloody discharge gumagalaw naman
(threatened abortion, PPROM) Yes or No Sakit sa pag-ihi o hirap sa pag-ihi
○ anytime Yes or No Meron po bang matubig o madugong lumalabas sa
pwerta
○ 18-20weeks AOG (primi)
● Uterine contractions (naninigas)
○ 28wks AOG (Braxton-hicks)
Focused ROS: General Survey:
() Weight Changes
(/) Changes in appetite
() Fever
() Malaise
() Sleep Changes
Breast:
() Masses
() Discharge
() Tenderness
() Nipple Changes

Skin:
() Change in color
() Itchiness
HEENT:
Pulmonary:
() Cough
() Wheezing
Cardiovascular:
() Chest Pain
() Palpitations
() Leg swelling
Gastrointestinal:
() Nausea
(/) Vomiting
() Abdominal Enlargement
() Abdominal Pain
() Dysphagia
Genitourinary:
() Dysuria

() Joint swelling
(/) Weakness
() Headache
() Syncope
() Memory loss
() Polydipsia
() Polyphagia
() Polyuria
() Anxiety, depression, hallucinations, delusions, mood
changes (pagbabago sa emosyon, malungkutin, madali
magalit)
Past Medical History: Comorbidities:

● None
asthma, TB, sakit sa thyroid, PCOS, ● None
sajut sa dugo katulad ng anemia, sakit sa
puso Past Surgeries:
○ Naalala ninyo po ba kelan kayo ●
nadiagnose?
○ Altapresyon: Highest, usual, most Injuries/Accidents:
recent BP ●
○ Diabetes: controlled ba, and what
medication she’s taking Blood transfusion:
● Past hospitalizations/surgeries:
● None
Naospital na po ba dati? Kailan? Saan?
Immunizations:
Anong ginawang operasyon?
● None
○ Always ask year, reason for
operation, any complication? Current Medications/Supplements: None
● Blood transfusion: Nasalinan na po ba ● Generic Name:
ng dugo? ● Brand:
● Immunizations: Nabakunahan na po ba ● Dose:
laban sa cervical cancer o HPV vaccine? ● OD/BID:
Tetanus? COVID-19 vaccine? Allergies:
● Current Medications/Supplements: May ● Shrimp
mga gamot po ba kayong iniinom ● Mefenamic acid
wala?
or labs
resulta?
po bang bukol?
Family History: Father: HTN

DM, HTN, CA (breast, cervical, Mother: DM
endometrial, ovarial), asthma, heart Siblings:
diseases Other family members:
PCOS and other
genetic gyne disease None
Personal and Social History:

Diet: Chicken, pork, vegetables
meal/pagkain nyo? (ex: kanin, Activity Level/Exercise: No
manok/baboy/beef, gulay) Smoking: No
● Nag eexercise po ba kayo? Ano po yung Alcohol Intake: No
pinakaphysical activity niyo? Illicit drug use: No
● Naninigarilyo po ba kayo? Kailan po
nagsimula? Ilang packs po sa isang araw?
No travel, exposure to COVID
Hanggang ngayon po ba? Bakit po kayo
tumigil?
● Umiinom po ba kayo ng alak? Palagi po ba?
honest na kasagutan nyo. Gumagamit po ba
OB-GYNE History
Menstrual History: Menarche (kelan unang niregla): 12y/o

MIDAS Interval (pagitan 1st and last): regular, (monthly)
● Ilang taon po kayo nung una kayong niregla? Duration ( ilang araw nag reregla): 3 days
● Regular po ba kayo nireregla? Kunyari ho April Amount (gaano kadaming napkin ang nagagamit, anong
5 niregla kayo, kailan po ninyo ineexpect ang klaseng napkin po ang gamit? Regular or yung night): 3
susunod nyong regla? pads
○ If irregular: mga gaano po katagal na Symptoms:
hindi kayo nireregla? Mga ilang
buwan po kayong hindi dinadatnan?
LMP June 1-3, 2021
PMP: May 5, 2021
AOG: 84/7 = 12 weeks AOG
tuing wnagreregla? Tulad ng Sakit sa puson, EDC: March 8, 2022
Obstetrics History: G1P0

● Nabuntis na po ba kayo dati?
○ If nakunan, tanungin kung alam Gravidity:
ang dahilan? Niraspa po ba yung
Parity:
abortion?
G1 (Year):
● GP (TPAL) nasabi nyo po kanina may ● BB boy/girl?
anak po kayo ● AOG
● G: tanong ko lang po kung Ilan na po ang ● BW
anak ninyo? Iisa lang ba ang ama sa ● NSD or C/S
lahat? Nakunan na ba kayo?
○ Indication:
○ Yung unang anak niyo, kailan
● Where:
pinanganak?
○ Ilang buwan siya nung ● Complications:
pinanganak?
○ Babae o lalaki?
○ Normal delivery or CS? LMP: (natatandaan nyo pa po ba yung huling regla
■ If CS: Ano po ang rason? ninyo? Kelan po yung unang araw?):
○ Saan kayo nanganak? Sino ang PMP:
nagpaanak - doctor po ba or
midwife?
○ Ask birth weight and length of
baby
**ask during HPI already Who did and Where Prenatal Care is being done?
When is the first and last consult?
Prenatal check up How frequent is the Prenatal Check-up?
● Kelan last prenatal check up? Laboratories done: ● CBC
● May laboratory po ba ginawa ● Urinalysis
noon? ● FBS OGTT
○ UTZ (gestational sac: Medications:
5-6wks)
○ Urinalysis Always ask for the ff information every PNCU (PreNatal
○ CBC, Blood type Check Up): Signs & symptoms experienced by the patient
○ FBS
○ Hepa B
○ VDRL
● 24wks & 32wks: OGTT Multivitamins/ Prenatal milk
● Medications? Folic acid supplement
Iron supplement
Calcium
Immunizations:
Tetanus Toxoid
Hepatitis B
Influenza
Pneumococcal
Laboratory tests requested:
CBC, platelet count
Blood typing
HBsAg
VDRL / RPR
HIV Testing
● Ultrasound (date done) 2 months
Only ask if pertinent to History of discharge?
case: has multiple Vulvar itchiness?
partners, or partner’s Ulcerations?
occupation can be Warts?
related for some sexual Pap smear with dates and results (last year, normal findings)?
infection
(vaginal discharge
symptom)
Sexual History Coitarche: 1

• Important to ask the No. sexual partner/s: 1
occupation of partner
o ex. call center agent: high Occupation of Partner/s:
risk for STD Regularity: (Gaano po kadalas)
• Elicit promiscuity of patient
(risk factor for STDs like HIV) Associated symptoms: none (dyspareunia, bleeding)
Date of last sexual contact:
Contraceptive History Type of contraceptive used: none

Generic/brand name:
Duration of use:
Reason for choice
Effectiveness of method:
PHYSICAL EXAM
General Survey Mental Status:

- Conscious, coherent, ambulatory, not in cardio respi distress,
oriented to 3 spheres
Vital Signs BP: 110/70 (d ko sure pero normal)

HR: 80
RR: 18
Temp: 37.2
Sp. O2:
Anthropometric Data Height: 5’5

Weight (Prepreg): 118 lbs
Weight (Current): 120lbs
BMI (Prepreg):
BMI (Current): 22
Skin Warm to touch, appropriate skin turgor, () pallor, () jaundice, () cyanosis, ()
active dermatoses, () ecchymoses - unremarkable
HEENT Chloasma? Melasma?

Epulits
EYES: Head:
Walang naman Eyes:
problema sa ● Pink palpebral conjunctiva
paningin?
Ears:
Walang panlalabo Nose:
ng paningin? Mouth:
pagkaduling? Neck: Unremarkable
MOUTH: ● Thyroid midline and moves with deglutition, Thyroid not enlarged, (-) bruit
Pagdudugo sa ● No palpable cervical lymphadenopathy
gilagid? ● JVP
Pagkawala ng
panlasa?
NECK:
May napansin po
ba kayong bukol
sa may leeg?
Chest ● Adynamic Precordium

● No murmurs
INSPECTION
Lungs Inspection: No deformities (pectus excavatum
PALPATION
Tactile fremitus
PERCUSSION
Dull, resonant, hyperresonant
AUSCULTATION
Clear breath sounds
Breast Inspection
If pertinent? Any gross abnormality on the breast
Asymmetry
Before assuming asymmetry, always ask if it is always have been asymmetrical
The dominant side usually appear larger than the other side
Ngayon, papahubarin ko po kayo ng
pangitaas para mas ma-examin ko Swelling none
po ang inyong dibdib, ok lang po ba
yun?
Masses none
Skin Changes
• Wash hands Nipple Changes dark
• Confirm patient details Pressing into hips
• Explain Examination (Contraction of Pectoralis Major)
• Gain Consent Hands behind head
• Ensure a chaperone is o Push elbows back and lean forward (will exacerbate skin dimpling)
present o Male gynecologist
- should be accompanied by
a
female assistant
Palpation
• Expose patient Asses:
• After examination:
o Thank Patient Asymmetry?
o Wash Hands Swelling?
• Self-breast exam is
recommended once a month Mass
after
menstruation
Location
o Best time: 1 week after Size/Borders
menstruation
▪ Hormone has less effect in Consistency
the breast Fluctuance
o While woman is taking a
bath • Clinical (done by the Fixation
physician) breast exam once
a year
Examine Axillary Lymph Nodes
or every 2 years together with Size
pap smear
• OB-GYN - only perform Consistency
diagnostic o If biopsy is needed,
refer to surgeon • High risk for
Fixation
breast CA = request Examine Regional Lymph Nodes
• Not high risk = request Infraclavicular
mammography at age 50 Supraclavicular
• Non-palpable lesions can be
detected in mammography Cervical
Abdominal I: size, shape, describe striae (color), scars (location, length,

hypertrophic vs keloid)
- flat
OB part: - Red striae below umbilicus
● FH (16-30wks) Flabby, Palpable midline mass, Fundus 1cm (fingerbreath) below the
○ Fundus to umbilicus est 19 weeks
border of the
symphis pubis A: character and frequency of bowel sounds normoactive -
● FHT (20wks
auscultation) FHT: 150bpm, regular
● Leopolds’ - 150, regular
Maneuver - Soft, no tenderness
(28wks) Pe: Tympanitic, dull, resonant
● Uterine
contractions Pa: Mass palpated, tenderness on RLQ, with rebound tenderness on deep
monitoring palpation, no rigidity, no guarding, soft
non tender
(+) Psoas sign

(+) Obturator sign
(-) Rovsing's sign
Palpation: FH= 31cm EFW= _____kg
Leopolds
LM1 (Fundal Grip) - 1 fingerbreadth below the umbilicus Determines
what fetal part occupies the fundus - hard, ballotable
Cephalic presentation: large nodular body representing the buttocks or
lower extremities
Breech presentation: hard, freely moveable and ballotable part
Shoulder presentation/ Transverse lie: empty
LM2 (Umbilical Grip) - fetal back on left
Determines on which maternal side is the fetal back Fetal back:
resistant convex structure
Fetal small parts: numerous nodulations
LM3 (Pawlik’s Grip) - soft nodular mass
Determines what fetal part lies over the pelvic inlet If fetal head
(cephalic presentation) is not engaged: movable, round, hard body
palpated
If lower pole of fetus is engaged, head is fixed.
LM4 (Pelvic Grip)
Determines on which side is the cephalic prominence In flexion attitude,
cephalic prominence is on the same side as the small parts
Peritonitis (board like rigidity)

(-) Tenderness
Genitourinary CVA Tenderness?

Cva = acute
pyelonephritis
Extremities ● Presence of edema?

● Pulses full and equal = 2+?
● Deformities?
● varicosities
Pelvic External Genitalia; Inspect the Vulva - normal
Ask the person to void ● Scars (-)
first ● Erythema
- Inspection ● Bleeding
● Discharge
Introduce yourself
Confirm patient details
● Gross lesions
o Patient’s name and date of ● Masses
birth Inquire about possible
pregnancy Check patient’s ● Rash/Vesicles/Ulcerations
understanding of the procedure
● *Pubic Hair Distribution (inverted triangle, right mediolateral episiotomy
o Explain that light vaginal scar, parous opening
bleeding or spotting may occur
Ensure a chaperone is present
- Parous introital opening
o For male physicians, always
ask a female colleague
to accompany you
Gain consent
Always ask to empty the bladder
prior to the procedure
o Except on cases on introital
mass, prolapse and
Gather the equipment to be

used o Gloves
o Speculum
o Lubricant
o Sample Pot
popsicle stick can also be
used)
Speculum Exam
- Only do if early ● Cervix: Violaceous, smooth with no bleeding per os, no masses
pregnancy, or ● Vagina: smooth, slightly purplish, no lesions
presenting with ● Cervix:
○ D-ilatation:
vaginal
○ Effacement
discharge ○ P-osition
○ Consistency
● Speculum Exam ○ P-resentation
- Hold the handle ○ S-tation
of the speculum
with your ● Inspect the Cervix:
dominant hand, ● ○ Color? Cervical ectropion - violaceous
and ● ○ Ulcers (-)
● open the labia ● ○ Masses/ Polyp (-)
minora with the
● ○ Discharge (amount, color, description) - minimal bleeding Shape of
other one (use
thumb and 5th
external os - fish mouth
finger). Insert the
CLOSED *ask for discharge: mucoid, bloody or watery (pooling - to confirm pprom)
speculum gently, - Can ask px to cough to make sure if presence of pooling
sideways at first,
then slowly rotate
to the normal
position, then
gently open the
speculum. Inspect
the cervix.
INTERNAL CERVIX:
EXAMINATION (IE) ● Long, soft, or closed
● No abnormal nodule or masses
Don’t do if the vaginal ● No Cervical motion tenderness
bleeding is on the Bishop score:
second half of ● Cervix:
pregnancy ○ D-ilatation:
○ Effacement
3 months AOG don’t do ○ P-osition
adnexal mass anymore; ○ Consistency
14-16wks AOG (only on ○ P-resentation
first trimester) ○ S-tation
(-) Cervical Motion Tenderness
Clinical Pelvimetry:
When px is presenting UTERUS:
uterine contractions ● Uterus was enlarged to AOG, firm, anteverted, movable, non tender
(first stage of labor) ● Example: uterus is enlarged to 4 months size, boggy, with slight ballooning
of the isthmic portion Ovaries adnexa cannot be assessed
Bimanual Exam ADNEXAL: Can the adnexal still be examined? Tenderness?
● No adnexal masses nor tenderness (R difficult to assess d/t pain)
● Adnexa cannot be assessed if uterus is enlarged to 3 months size!
Clinical Pelvimetry

• A rectal examination is
primarily done if the patient is a
• Rashes
virgin or has no sexual history. • Hemorrhoids
Do not do
vaginal exam given those • Anal Fissure
indications
• Bleeding
• Confirm patient details • Fistulae
○ Assure that it will be a
• Abscesses
quick examination
○ Assure that the patient may
opt to stop the procedure if Palpation
there is any discomfort ● Lubricate the finger
• Gain Consent ○ Use the Index Finger
• Ensure a chaperone is
present (especially if Male ● Insert the finger gently into the anal canal
Gynecologist)
○ Gloves
○ Apron ● Palpate for the following:
○ Lubricant
○ Paper Towels
○ Cervix
• Wash hands thoroughly ○ Size of the Uterus
• Wear apron and gloves
• Position the patient
○ Adnexal area
○ Males = lateral recumbent ▪ Ideally, there is nothing to feel or palpate in the
position adnexal area
○ Ideally for a Gynecologist, ▪ Any mass that can be palpated in the area is
the dorsal lithotomy position
should be maintained considered a suspicious abnormality
○ After IE, you can insert one ● Shift to the right side and left side
finger into the rectum unless ● Assess the anal sphincter tone
you are going to do a
rectovaginal exam meaning ○ Ask the patient to squeeze the finger
index finger in the vagina, third ● In rectal/rectovaginal exam, you can palpate for tender
• Inspection
• Palpation
• Withdraw and inspect finger
and assess
○ Blood
○ Stool
○ Mucus
• Wipe away excess
lubricant • Cover the
patient
• Dispose the equipment
into a clinical waste bin
• Wash Hands
• Summarize the findings
examination for further
assessment

Palpate the tissue in between the rectum and the vagina (rectouterine pouch of
douglas)
Nodularity
Tenderness
Masses
For the rectal finger, palpate the integrity of the rectal mucosa and presence of
mass.
Rectal Mass
● From the pelvic exam, gently slip the middle finger to the rectum while the index finger remain
in the vagina
● Insert the finger in the full length of the vagina .
● Palpate the tissue in between the rectum and the vagina
(rectouterine pouch of douglas) ○ Palpate for nodularity,
tenderness, and masses
● For the rectal finger, palpate the integrity of the rectal mucosa and presence of mass.
● Example:
○ A patient with an enlarged ovary wherein we cannot examine
properly by vaginal exam
● Rectovaginal exam may be
warranted if there are inconclusive results from the vaginal exam ● Index finger is inserted into
the vagina, and the Middle
finger is inserted into the rectum (anal opening)
● Generally:
○ Vaginal Exam, Rectovaginal Exam and Rectal exam will not do harm in a pregnant patient
● Enterocele can be identified in patients with pelvic organ
prolapse.
● Why do we need to end a
gynecological exam with a vaginal exam (not appreciated enough with IE)
○ You can sweep your finger at the back of the uterus, to palpate uterosacral and cul de sac
area
○ For ovarian cysts that is toward the back
▪ unlike in lateral ovarian cyst that is appreciated on IE
SALIENT FEATURES
Age: 25 Vital signs were all normal

Nulli/multi:G1P0 BMI 22, current 120 lbs, pre-pregnancy 118 lbs, 5’5”
Systemic pe: unremarkable except:
NSD/CS
● Abdomen:
Single/married: Married for 1 year
Religion: Catholic ○ RLQ tenderness, (rebound tenderness on
Occupation: Housewife, lives in QC deep palpation)
CC: “Sumasakit tiyan” ○ (+) Psoas and obturator sign
● 3-4 days ago (4/10) ○ (-) Rovsing
● Nung una umiikot , migrated to RLQ (8/10) ● Pelvic:
Generalize then localized to the RLQ ○ Violaceous cervix, no bleeding (chadwick)
● Intermittent
○
● Twisting in character
Vomiting - 5 days ago (could be normal at this AOG)

● Fatigue
● 3-4 times (4 days ago) -> 5-6 times (now) No (pertinent negatives) ___________
No appetite External genitalia: inverted triangle pattern; no lesions
Speculum exam revealed:
No headache
Cervix: Violaceous, smooth with no bleeding per os, no
High temp (mainit pakiramdam) undocumented fever
Allergic to shrimp and mefenamic acid masses
Vagina: smooth, slightly purplish, no lesions
(+) pregnancy test - 2 days ago
Internal examination showed:
Spotting ● Long, soft or firm, or closed
● ● No abnormal nodule or masses
Father: HTN ● No Cervical motion tenderness?
Mother: DM ● Uterus is firm enlarged up to level of symphysis
pubis
Regular menses (3days)
● Right adnexa difficult to evaluate due to pain
LMP: June 1 - June 3 2021
AOG 12 Weeks (29+31+24 = 84 / 7 = 12)
PE:
Risk factors: Labs:
Symptom (10 danger signs of pregnancy):
●
CLINICAL IMPRESSION:
G1P0 Pregnancy uterine at 11-12 weeks AOG by LMP, Acute Appendicitis probably ruptured?
Signs and Right lower quadrant tenderness

Symptoms ● Rebound tenderness
● Persistent abdominal pain and tenderness are the most reproducible findings.
● Abdominal guarding
● Temperature >37.8 C
● Since direct contact between the area of inflammation and parietal peritoneum is
impeded, there is less rebound tenderness or guarding. The gravid uterus may also inhibit
contact between the omentum and the inflamed appendix.
Physical ● Direct and rebound tenderness on Right lower quadrant

examination
● Positive Psoas sign, Obturator,
Diagnostic/
ancillary (make
sure to request
for labs that will
be
cost-effective)
CBC !!
- Increased WBC in acute appendicitis (leukocytosis with polymorphonuclear prominence)
- Approximately 80 percent of nonpregnant patients with appendicitis have a preoperative
leukocytosis (white cells >10,000 cells/microL) and a left shift in the differential
- Mild leukocytosis can be a normal finding in pregnant women: the total leukocyte count
may be as high as 16,900 cell/microL in the third trimester, rising as high as 29,000
cells/microL during labor, and a slight left shift may occur.
Urinalysis !!
- Microscopic hematuria and pyuria may occur when the inflamed appendix is close to the
bladder or ureter: rare
Transabdominal ultrasound
- Thickened wall
- Noncompressible blind ended tubular structure in RLQ w max diameter greater than 6mm
- Pregnancy location viability
If US not available and need to establish viability of fetus, do Hand-held Doppler

- FHT via doppler
RT-PCR
- r/o covid
● Serum bilirubin (total bilirubin >1.0 mg/dL)

○ Mild elevation
○ Marker for appendiceal perforation
● CRP
○ Elevated
○ Nonspecific sign of inflammation
1st Prenatal Check-Up:

● TVS
● CBC
FBS: screening for overt DM/GDM

Urinalysis: screening for asymptomatic bacteriuria
CBC with platelet count: screening for IDA
● First trimester sonography would include aging of the fetus especially in the first trimester via the
crown rump length (CRL).
● (Example of a report: TVS showed a single live intrauterine pregnancy, 12-13 weeks AOG by CRL,
with good cardiac activity.)
- Yolk sac: 5 weeks
For AOG:
- Fetal biometry - >13 wks (14-26 weeks) (biparietal diameter, femur length, abdominal
circumference, head circumference)
- FH: 16-30 +-2 weeks AOG accuracy: measure from superior border of symphysis pubis to fundus
- BPS
- Fetal tone
- 10x every 2 hours
- Fetal breathing
- Nonstress test - to make it 10/10 (not done unless 1 in BPS is abnormal since expensive)
- Reactive fhr: 2 or more episodes of acceleration of >15 bmp and of >15s
- Contraction

(Include
therapeutic and
preventive; Management:
management
goals;if kaya Preoperative:
gawing specific ● IV hydration
like dose etc) ● Pain management (opioids)
● IV antibiotics
○ 2nd gen ceph + clindamycin or metronidazole
● NPO patient
● Prophylactic tocolytic (Isoxsuprine) IV drip preop → switch to oral post-op when 100cc left,
to be given TID for 24 hrs
○ To quiet down and lessen hypogastric pain
● Progesterone
26 weeks- high risk pt

28 weeks- start EFM
Definitive: Laparoscopic(?) Appendectomy

- Laparoscopy is the preferred surgical approach in early pregnancy
Open Appendectomy
- Parasagittal and midline considering interstitial/cornual
- Allows adequate exposure of the abdomen for diagnosis and treatment of
surgical conditions that mimic appendicitis
Watch out for complications such as:

● Surgical site infection
● Hematoma
● Postoperative ileus
Preventive:
Underweight would have to maintain an increase of 1 lb per week; if overweight 0.6 lb/wk; if obese 0.5 lb/wk
I Monitor input (IV) and output (urine output - 30cc/hr) every shift and record

Differentials Appendicitis Acute ONG Ectopic Molar

cholecystitis Pregnancy Pregnancy
Signs and General Fever RLQ pain 12 weeks (first 12 weeks (first
Symptoms abdominal pain RUQ pain half) half)
then migrated to Nausea Hypogastric pain Hypogastric pain
RLQ pain Spotting Vomiting
Worsening of No appetite Missed menses Irregular bleeding
symptoms (Pain (+) PT (may be
grade 4/10 to Generalized pain Triad of ectopic spotting/hemorrh
8/10) initially age)
(+) PT
Tenderness??
Physical Direct and (-) Jaundice Adnexal mass

examination rebound Anicteric sclera Tenderness on
tenderness palpation of lower
Tenderness? abdomen and
+ Psoas sign adnexa
+ Obturator sign
(-) Rovsing sign
Reason for R/o? RUQ pain (-) cervical motion Uterus is

tenderness enlarged to AOG
(-) bulging
Anicteric sclera culdesac No passage of
(-) adnexal mass grape like tissues
and tenderness
Pain not
migratory
Diagnostic/
ancillary
Management
ADDITIONAL NOTES:
DISCUSSION
Salient features 25 y/o, G1P0 (0000), 32 weeks AOG
CC: “spotting”
5 hours PTC, had two episodes of continuous vaginal spotting No
dysmenorrhea, no nausea and vomiting
FHT 150/min regular

Fundic Height: 31 cm
Leopold’s Maneuvers
● LM1 - hard ballotable mass CEPHALIC
● LM2 - fetal back left
● LM3 - soft nodular mass on hypogastrium BREECH No
tenderness
Violaceous cervix with minimal bright red bleeding from the os
Clinical Impression G1P0? (0000), Pregnancy uterine, 32 weeks AOG, breech presentation, 3rd
trimester bleeding to consider placenta previa
Why placenta previa? Painless vaginal bleeding in the 3rd trimester

● Minimal bright red bleeding
● No tetanic contractions - painless
Ddx 1. Abruptio Placenta
a. Premature separation of the normally implanted placenta
First loop notes (Sept): (fundal area), either partially or totally,
from its implantation site before delivery
First loop notes b. Classically presents as PAINFUL uterine
(July Group) bleeding.
c. RFs: >40 yo, hypertension, multiparity, prior
abruption, smoking, trauma (eg domestic
violence -- but not ask in history)
2. Placenta Previa
a. A placenta implanted somewhere in the lower
uterine segment, either over or very near the
internal cervical os.
b. It presents with PAINLESS VAGINAL BLEEDING in the second
half of pregnancy.
3. Placenta Accreta Syndromes
a. Include any placental implantation with
abnormally firm adherence to the myometrium
because of partial or total absence of the decidua
basalis and imperfect development of the
fibrinoid or Nitabuch layer.
b. Antenatal bleeding as a consequence of
coexisting previa. Adhered placenta encountered
during the 3rd stage of labor.
c. (-) RFs:
■ Associated previa
■ Prior cesarean deliveries
■ Curettage or endometrial ablation or
hysteroscopic resection of submucous
mucosa
■ >35 years old
■ multiparity
■ Hx of postpartum endometritis
4. Preterm Labor
a. Unlikely: there are no contractions
b.
Work - Up Transvaginal ultrasound - transducer can induce bleeding

Transabdominal ultrasound
● BPS
○ Movement
○ Breathing
○ Heart Tone
○ Nonstress test - to make it 10/10
○ Amniotic fluid level
● Biometry
● Know the location of placenta
Final Diagnosis
Interpretation of utz findings: marginalis
** low-lying placenta previa (does not cover the os, 2cm away from the os)
-- nice to ask the distance of placenta from the os
G1P1 (0000), Intrauterine Pregnancy 32 weeks AoG - cephalic, Placenta

Previa (marginalis)
Management Bedrest, reduced activity, and avoidance of intercourse
Antenatal corticosteroids for lung maturity

● In anticipation of recurrence
● DOC: Betamethasone 12 mg every 24 hours for 2 doses ● Alt:
Dexamethasone 6 mg every 12 hours for 4 doses
(If patient has contractions, give tocolytics - but patient currently has none)
If there is recurrence - go to ER
If totally covering the OS, management - give steroids aside from bed
rest and reduced physical activity
● DOC: Betamethasone 12mg IM 2 doses 24 hours ● Alternative:
Dexamethasone 6mg IM 4 doses 12 hours ● Deliver at least 24 hours
from the last dose of steroids
Schedule for elective delivery at 36 to 37 weeks via cesarean

section
● Plan for cesarean section and possible hysterectomy if there is
uncontrolled postpartum hemorrhage or
Placenta Accreta Syndrome
If there is recurrent bleeding but heavy, need to schedule emergency

CS
Prevention
Concerned more of FHT, FH, Leopold’s maneuvers, in 32 weeks AOG than the bowel sounds Give first
impression and formulate plan of treatment

Can occur in primis

Age
Multiparity
CS delivery
HPN
Prior Abruptio
Trauma or accident
Prior history of trauma to endometrium (hx of curettage, hysteroscopy of submucous myoma) **but this
patient no previous surgeries or trauma
General comments:
● Be more focused
● Ideally, 3rd trimester bleeding and thinking of Placenta Previa refrain from doing IE and go for
ultrasound
● Missed in hx:
○ History of contact the night before prior to bleeding (since vaginal wall and cervix
edematous and swollen in pregnancy → easily traumatized)
NOTES FOR CARES
AS, 25 yrs old, married who came in for consult due to abdominal pain which started 4 days ago
Positive pregnancy test 2 days ago
“Twisting” abdominal pain then transferred to the right side
From 4/10 4 days ago to 8/10 now
Comments:
- After getting the CC, clerk asked right away if the patient took a pregnancy test. The clerk should ask
first everything and expound about the CC (abdominal pain) before asking for other details like this.
- Positive pregnancy test go straight to LMP, straight to MIDAS. Deviation on the history can be
done, don’t dwell too much on the history.
- Clerk was able to elicit one of the 10 danger signs of pregnancy (persistent vomiting) -- natanong ba
yung iba? Huhu- Hindi nacomplete huhu
- No need to say “punta po tayo sa OB gyne history…” since this could sound like medical jargon for
the patient. Just go straight to the questions
- Better organization and time management - after running down the history, clerk went back to the
HPI to confirm and ask more details about the CC
- Prioritize the questions asked for the focused history
- Clerk asked if the patient took a pregnancy test early in the HPI but asked the LMP towards
the end. (same comment from doc)
- Clerk assign forgot to ask the patient to void even before the start of the PE. This can save time in
doing the Physical Examination.
- Limited time so clerk should've taken a focused PE but it’s still good that the clerk wanted to be
thorough from head to toe
- Physical Examination for Appendicitis which are the Rovsing’s, Psoas and Obturator was not done.
This could rule out Appendicitis since the chief complaint was abdominal pain with localization to the
RLQ.
- The Rovsing’s, Psoas and Obturator sign were elicited towards the end of the PE which
should’ve been done during the abdominal examination.
- Murphy’s sign was not elicited which would have ruled out the Cholecystitis.
-
Topic
Facilitator ACT
Clerks Gutierrez, Sasha & Hachuela, Bernadette Anne L.
Date 08/23/2021
HISTORY

lang kayo at lahat ng ating mapag-uusapan ay mananatiling confidential, so okay lang po ba na simulan ko na?
● Ano po ang buong pangalan mo?
● Ano po ang inyong trabaho ngayon?
● Ano pong civil status nila, kasal na po ba?
● Ano pong napagtapos nila sa pag-aaral?
General Data Name: Maria Dela Cruz

Age > 35 (risk factor for Previa, Abruptio) Age: 22
● nasusuka/nagsusuka
○ Gaano kadalas at kadami
Birthdate:
● Pakiramdam na laging pagod Birthplace: Manila
● Madalas ang pag-ihi Address: Blumentritt
● Delayed ang menses Marital Status: Live in partner for 1 year
● Napapansin pagbabago sa dibdib/breast Nationality: Filipino
● Sa balat
Religion: Catholic
● Chief Complaint: Ano po ang rason kung
bakit po kayo nagpa-konsulta ngayong Occupation: Housewife
araw? Educational attainment: 1st yr college
● Nag-pregnancy test na po ba sila? Ano
pong resulta? CC: Prenatal Check Up (Kabuwanan, every week need na
● Matanong ko lang din po, kelan po ang magcheck up)
unang araw ng huling regla nila? Tapos
hanggang anong araw po yon? Regular
naman po sila? 4 mos AOG (around 16wks) - 1st prenatal. This is the 4th
● First time niyo po bang magpaconsulta
ngayon? Ano pong mga tests ang Lab tests: Normal naman accd to resident. UTZ on first check
pinaggawa? Normal naman po mga up (4 mos) showed compatible AOG.
results?
● First time niyo po ba magbuntis? Pregnancy test:
○ UTZ (gestational sac: 5-6wks)
○ Urinalysis LMP:
○ CBC, Blood type
○ FBS AOG: 37 1/7 weeks AOG
○ Hepa B
○ VDRL Medications:
● 24wks & 32wks: OGTT
● Increased BP (130/90, 140/90) - given methyldopa (500
mg/tab, 2x a day, compliant, aldomet)
○ Urinalysis - OKAY
○ Usual BP - 110-120/70-80
○ Highest - 140/90
History of Present Symptom 1: Naninigas ang tiyan (few hours PTC)
Illness: ● 4x in an hour
O: Kailan po ninyo unang napansin? ● Good fetal movement
D: Gaano katagal kapag dinudugo kayo? ● Duration:
Tuloy-tuloy po ba ang pagdudugo? ● Location: whole abdomen
C: Masakit po ba? Marami po ba? ● Character: mahigpit, parang hinahatak
- Abruptio (painful) ● Pain 6/10
A: May ginawa po ba kayo anung
napansin ninyo yung pagdudugo niyo? Diagnosed with Hypertension, 35 weeks AOG
A: May iba pa po ba kayo
nararamdaman bukod doon?
Dysmenorrhea? Pagkahilo? Pamumutla? Onset: Kaninang madaling araw
R: May ginagawa po ba kayo dito para Location:
mawala? Duration:
S: If masakit, gaano kasakit? Pwede niyo Character:
po bang i-rate from 1-10, 10 po ang Aggravating:
pinakamasakit Alleviating:
Relieving: none
● Blurring of vision, headache, Temporality: continuous from midnight to now
convulsions, edema of hands and Severity: 6/10
feet (preeclampsia)
● Fever, dysuria (UTI) Ask for Danger signs of pregnancy
● Abdominal pain/hypogastric pain->
preterm labor and abortion N Meron po bang pagsakit ng ulo
● Persistent nausea and vomiting-> N Panlalabo ng mata
GTD and multifetal pregnancy N Hindi nawawalang pagsusuka
● Watery / bloody discharge N Lagnat at panginginig ng katawan
(threatened abortion, PPROM) Y/N Pamamanas ng kamay at paa
● Decreased fetal movement Y Sakit sa tiyan or nararamdamang contractions
● Uterine contractions ● Ilang contractions po kada oras? May pagitan po ba (ilang
minuto po) or tuloy tuloy? Umiikli po ba yung interval or
pagitan habang tumatagal? Mas sumasakit po ba or lumalala
yung contractions habang tumatagal?
● Started kanina madaling araw “naninigas”
● Every 4x/hr (dapat 12/hr para in labor),
● Mahigpit parang hinahatak yung buong tiyan
N Napansin po bang pagbabago sa paggalaw po ni baby?
Nabawasan po ba?
● Ilang fetal movements po ba kada oras? Di nabibilang,
gumagalaw naman
N Sakit sa pag-ihi o hirap sa pag-ihi
N Meron po bang matubig o madugong lumalabas sa pwerta
Only ask pertinent to CC and () Weight Changes
focus on those related to () Changes in appetite
danger signs () Fever
() Malaise
() Sleep Changes
Breast:
() Masses
() Discharge
() Tenderness
() Nipple Changes

Skin:
() Change in color
() Itchiness
HEENT:
Pulmonary:
() Cough
() Wheezing
Cardiovascular:
() Chest Pain
() Palpitations
() Leg swelling
Gastrointestinal:
() Nausea
() Vomiting
() Abdominal Pain
() Dysphagia
Genitourinary:
() Dysuria

() Joint swelling
() Weakness
() Headache
() Syncope
() Memory loss
() Polydipsia
() Polyphagia
() Polyuria
magalit)

● No DM (OGTT)
asthma, TB, sakit sa thyroid,Cancer, ● None
stroke, sakit sa puso, sakit sa dugo tulad
ng anemia Past Surgeries:
○ Naaalala nyo po ba kailan kayo ●
nadiagnose? Kahit taon lang po?
○ ALTAPRESYON: ask most recent bp,
usual bp and highest bp
Injuries/Accidents:
○ DIABETES: ask if controlled ang blood ●
sugar or may iniinom na gamot?
● Past hospitalizations/surgeries: Blood transfusion:
Naospital o naoperahan na po ba dati? ● None
○ Always ask year, reason for
operation, any complication? Immunizations:
● Injuries/ Accidents: Naospital na po ba kayo ● No flu
dati or naaksidente? Kailan? Para saan? Anong ● No covid
sakit? Anong ginawa?
Current Medications/Supplements:
ng dugo? ● Generic Name:
● Immunizations: Kumpleto po ba kayo sa ● Brand:
bakuna? Nabakunahan na po ba laban sa ● Dose:
cervical cancer o HPV vaccine? ● OD/BID:
Nagkaroon na po ba ng flu vaccine? ● Vitamins
Tetanus? COVID-19 vaccine? Complete ○ Hemarate ferrous sulfate OD
na po dose? ● Methyldopa (Aldomet)
● Current Medications/Supplements: May ○ 500 mg BID
mga gamot po ba kayong iniinom ○ Compliant
ngayon? Para saan po ito? Generic ○ If low BP 110-120 - do not take
name, brand, dose? Ilang beses po sa ○ Takes effect but past few days napagod kasi
isang araw? Self-prescribed/ doctor inaayos room ni baby (140/90 - did not
prescribed? Kelan pa po ni-reseta? decrease with medication)
pagkain o gamot? Sa pain relievers po Allergies:
wala? ● None
or labs
resulta?
po bang bukol?
Family History: Father: HTN
Sa pamilya niyo po, May history po ba ng Mother:
sakit tulad ng DM, HTN, CA (breast, Aunt: Diabetes
cervical, endometrial, ovarial), asthma, Siblings:
mga sakit sa puso, pcos, o ibang mga Other family members:
genetic na sakit po?
Patient’s HPN - diagnosed at 4 mos AOG (hindi ba 35

Personal and Social History: weeks AOG?)
meal/pagkain nyo? (ex: kanin,
manok/baboy/beef, gulay) Diet: avoids salty food
● Nag eexercise po ba kayo? Ano po yung Activity Level/Exercise: none
pinakaphysical activity niyo? Smoking: no
● Naninigarilyo po ba kayo? Kailan po
nagsimula? Ilang packs po sa isang araw?
Alcohol Intake: occasionally before pregnancy
Hanggang ngayon po ba? Bakit po kayo Illicit drug use: none
tumigil?
● Umiinom po ba kayo ng alak? Palagi po ba? No travel, exposure to COVID
honest na kasagutan nyo. Gumagamit po ba
OB-GYNE History
Menstrual History: M - 12 y/o

I - Regular
● Ilang taon po kayo nung una kayong niregla? D - 3 days
● Regular po ba kayo nireregla? Kunyari ho April A-
5 niregla kayo, kailan po ninyo ineexpect ang S-
susunod nyong regla?
○ If irregular: mga gaano po katagal na
hindi kayo nireregla? Mga ilang
LMP
buwan po kayong hindi dinadatnan? PMP
tuing wnagreregla? Tulad ng Sakit sa puson,

● Nabuntis na po ba kayo dati? AOG 37 weeks and 1 day
● GP (TPAL) nasabi nyo po kanina may
anak po kayo
Gravidity:
● G: tanong ko lang po kung Ilan po ang
Parity:
lahat ng pagbubuntis ninyo? Nakunan na
po ba sila? Ilang beses po? Kasali po ba
G1 (Year):
yan doon sa __ na sinabi niyo kanina? ● BB boy/girl?
Na-raspa po ba kayo nung nakunan? ● AOG
● Husto po ba silang lahat sa buwan nung ● BW
pinanganak ninyo? ● NSD or C/S
● May mga naging komplikasyon po ba? ○ Indication:
● Iisa lang ba ang ama sa lahat? ● Where:
○ Yung unang anak niyo po, kailan ● Complications:
po pinanganak?
○ Babae o lalaki?
○ Naka-ilang buwan po siya nung
pinanganak? Husto po ba?
○ Naalala niyo po ba yung timbang
at haba po ni baby
pagkapanganak?
○ Normal po ba ang panganganak o
cesarean po?
■ If CS: Ano po ang rason?
○ Saan kayo nanganak? Sino ang
midwife?
Prenatal check up Who did and Where Prenatal Care is being done?
- 1st:
Nakapagprenatal check up na po ba - 2nd:
sila dati? Saan po? Pang ilan na po - 3rd:
ito ngayon? Gaano po kayo kadalas How frequent is the Prenatal Check-up?
nagpapa-prenatal check up? Ano Laboratories done:
pong mga lab tests na pinagawa sa ● CBC
inyo Ano pong resulta? ● Urinalysis
● FBS OGTT
May mga gamot po ba kayong utz
iniinom ngayon? Mga iron? Folic
acid? Calcium? Multivitamins? Medications:
Obimin (multivitamin for pregnant)
● First prenatal usually: Sangobion (iron supplement)
○ UTZ (gestational sac: Part of the ‘History of Present Pregnancy’ if no
5-6wks) complaint. This will be the last part of HPP.
○ Urinalysis A separate entry if (+) complaint
○ CBC, Blood type
○ FBS Always ask for the ff information every PNCU (PreNatal Check
○ Hepa B Up): Signs & symptoms experienced by the patient
○ VDRL Focus on “Danger Signals of Pregnancy”
● 24wks & 32wks: OGTT Place of previous consult, weight, BP, FHT, etc
● nasusuka/nagsusuka Medications prescribed:

○ Gaano kadalas at kadami Multivitamins/ Prenatal milk
● Pakiramdam na laging pagod Folic acid supplement
● Madalas ang pag-ihi
Iron supplement
● Delayed ang menses
● Napapansin pagbabago sa dibdib/breast
Calcium
● Sa balat Immunizations:
Tetanus Toxoid
Hepatitis B
Influenza
Pneumococcal
CBC, platelet count
Blood typing
HBsAg
VDRL / RPR
HIV Testing
● Ultrasound (date done)
Gynecologic History: No History of STI/STD
● Nagkahistory po ba kayo ng No History of discharge
impeksiyon na naipapasa No Vulvar itchiness
sa pakikipagtalik?) No Ulcerations
● May Discharge
po ba na
lumalabas sa
ari?)
● (Pangangati?)
● (Pagsusugat?)
● Warts?
● Pap smear with dates
and results (last year,
normal findings)?
Sexual History Coitarche: 21

Pasensya na ma’am, medyo No. sexual partner/s: 1 (husband)
sensitibo at personal lang po ang Occupation of Partner/s: Online seller
mga susunod ko na itatanong Regularity: (Gaano po kadalas)
- Only ask if needed talaga Associated symptoms: (dyspareunia, bleeding) -
since ayaw to tinatanong ni Date of last sexual contact: no contact since got
doc mongon pregnant
- To know risk for cervical
cancer (sex at around teens
and no HPV vaccine)
• Important to ask the occupation of Family Planning none
partner
o ex. call center agent: high risk for STD
• Elicit promiscuity of patient (risk factor
for STDs like HIV) Type of contraceptive used: None
Generic/brand name:
Duration of use:
Contraceptive History Reason for choice
PHYSICAL EXAM

- Conscious, coherent, ambulatory, not in cardio respi
distress, oriented to 3 spheres
Vital Signs BP: 150/90 (took meds @ 6 am)

● Pre-pregnancy:
○ w/ meds
○ w/o meds
● Current:
HR: 88
RR: 20
Temp: 36.8

Weight (Prepreg): 110 lbs
BMI (Prepreg): 18.9 Normal
BMI (Current): 25.7
Skin Are there any lesions? Chloasma
None ● Irregular brownish patches over
face (forehead, bridge of nose,
Warm to touch, cheekbones) & neck
appropriate skin turgor, () Linea Nigra
pallor, () jaundice, () ● Brownish-black
cyanosis, () active hyperpigmentation of the midline
of abdominal skin (linea alba)
dermatoses, () Striae Gravidarum/Stretch marks
ecchymoses ● Reddish, slightly depressed
streaks
Spider telangiectasia
● Vascular and stellate marks on
the skin (face, neck, upper chest,
and arms)

Epulits
EYES: Head:
Walang naman Eyes:
problema sa paningin? ● Pink palpebral conjunctiva
Walang panlalabo ng
Ears:
paningin? Nose:
pagkaduling? Mouth:
MOUTH: Neck: Unremarkable
Pagdudugo sa gilagid? ● Thyroid midline and moves
Pagkawala ng with deglutition, Thyroid not
panlasa? enlarged, (-) bruit
● No palpable cervical
NECK:
lymphadenopathy
May napansin po ba ● JVP
kayong bukol sa may
leeg?
Lungs INSPECTION Symmetrical chest expansion

PALPATION Tactile fremitus
PERCUSSION Dull, resonant, hyperresonant

AUSCULTATION Clear breath sounds

● No murmurs
Breast Inspection
Ask for consent first Any gross abnormality on the breast - none
Asymmetry, masses?
• Wash hands
Swelling, Tenderness
• Confirm patient details Discharge (colostrum at 16 weeks)
• Explain Examination
• Gain Consent Nodularities
• Ensure a chaperone is Masses
present o Male gynecologist
- should be accompanied by Skin Changes
a
female assistant
Nipple Changes : deeply pigmented, enlarged, more erectile/everted
• Expose patient Areola: enlarged, more deeply pigmented
o Thank Patient
o Wash Hands
• Self-breast exam is Enlarged mammary glands, hypertrophic glands of montgomery (small elevations
recommended once a month
after scattered in areola)
menstruation
o Best time: 1 week after
menstruation Palpation
▪ Hormone has less effect in Asses:
the breast
o While woman is taking a Asymmetry?
bath • Clinical (done by the
physician) breast exam once
Swelling?
a year Mass?
or every 2 years together with
pap smear Location
• OB-GYN - only perform
diagnostic o If biopsy is needed,
Size/Borders
refer to surgeon • High risk for Consistency
breast CA = request
mammography at age 40 Fluctuance
• Not high risk = request Fixation
• Non-palpable lesions can be Examine Axillary Lymph Nodes
detected in mammography Size
Consistency
Fixation
Examine Regional Lymph Nodes
Infraclavicular
Supraclavicular
Cervical
Abdominal
I: Globular, (+) striae, no scars
Fundic Height: from border of P: Fundic height: 33 cm
pubic symphysis to fundus
Starts 16-18wks Leopold’s Maneuver - to know presentation
16-midway ● LM1 - buttocks
20-umbilicus
● LM2 (auscultation/doppler of back L for FHT) - fetal back left
Leopold’s Maneuver: Starts ● LM3 (presentation) -cephalic
28wks Contractions: moderate contractions, occurring every 5 minutes, 30 seconds in
-LM1:Fundal grip
(breech/cephalic) duration\
-LM2: Umbilical grip (fetal A: FHT: 130 bpm, regular
back L/R)
-LM3: Pawlick’s grip
(breech/cephalic) I: Shape, striae (color), scars (location, length, hypertrophic vs keloid)
-LM4: Pelvic grip *Not - Is it soft or flabby? is it flat or globular, is there NO presence of striae or scars (location,
routinely done* length, hypertrophic vs keloid)
- Soft, flabby, Globular, Red striae below umbilicus
Fetal Heart Tones (NV:
110-160bpm)
-TVS 6-8wks
-Doppler 10-12wks A: character and frequency of bowel sounds normoactive
-Steth 18-20wks
- FHT= 130bpm, regular
Pe: DON’T PERCUSS IN PREGNANT
Pa: Fundic Height: ___cm

○ 12 weeks: fundus at the level of the symphysis pubis
○ 16 weeks: midway
○ 20 weeks: umbilicus
Any mass palpated, tenderness (direct and rebound), board-ike rigidity,

guarding?
Uterine Contractions? (>20 weeks): ilan kada hour? Mild moderate or severe?
Leopold's Maneuver
LM1 (Fundal Grip)
- Cephalic presentation: large nodular body representing the
buttocks or lower extremities
- Breech presentation: hard, freely moveable and ballotable part


LM4 (Pelvic Grip)

Engaged or not?
Genitourinary CVA Tenderness?
Extremities ● Presence of edema - physiologic at term bc of venous compression

● Pulses full and equal = 2+?
● Deformities?
● varicosities
Pelvic ASK MUNA TO VOID
Normal looking
IE - don’t do if
second half of
pregnancy!! Hair distribution
Ask to empty bladder External Genitalia; Inspect the Vulva
● Lesions
Introduce yourself
● Scars
o Patient’s name and date of ● Erythema
pregnancy Check patient’s ● Bleeding
● Discharge
o Explain that light vaginal ● Masses
● Rash/Vesicles/Ulcerations
to accompany you Clinical pelvimetry
Gain consent
mass, prolapse and

used o Gloves
o Speculum
o Lubricant
o Sample Pot
used)
Speculum Exam -
not done in all
patients unless ● Cervix:
there is blood or - Normal: Violaceous, smooth with minimal, whitish, non-foul mucoid
abnormal discharge discharge
● Vagina: smooth, violaceous (Chadwick’s sign)
● Speculum Exam
- Hold the handle
of the speculum
with your ● Inspect the Cervix:
dominant hand,
○ Color: is it violaceous?
and
● open the labia ○ Ulcers:
minora with the ○ Masses/ Polyp:
other one (use ○ Discharge (amount, color, description) -
thumb and 5th ○ Shape of external os:
finger). Insert the - parous cervical os (fish mouth) or
CLOSED - nulliparous cervical os (circular)
speculum gently,
sideways at first,
then slowly rotate
to the normal
position, then
gently open the
speculum.
Inspect the
cervix.
INTERNAL CERVIX:
EXAMINATION (IE) ● Long, soft(Goodell’s sign), closed, posterior in location
Don’t do if the vaginal ● No Cervical motion tenderness
bleeding is on the ● Dila tation: cervix is closed so no
second half of ● Effacement: long so uneffaced
pregnancy ● Position: posterior
● Consistency
● Presentation: cephalic intact BOW
Bimanual Exam ● Station
Additional PE for patient:

BISHOP SCORE: 2
Clinical Pelvimetry:
Extremities: want to know presence of edema (if +3 anasarcus - significant)

● +1 can be physiologic at term because of venous compression
UTERUS: Compatible with AOG

is the uterus compatible with AOG?
● Uterus normal sized (if enlarged, ask for how many months size?), anteverted,
movable, nontender, consistency
● Example: uterus is enlarged to 4 months size, boggy, with slight ballooning
ADNEXAL:
● No adnexal masses nor tenderness - cannot palpate anymore bc term na
● cul de sac: deep fornices, bulging of fornices, no tenderness
Rectal Exam ONLY IF INDICATED

Inspection
virgin or has no sexual history. • Rashes
Do not do
vaginal exam given those • Hemorrhoids
indications
• Anal Fissure
• Confirm patient details • Bleeding
• Fistulae
quick examination • Abscesses
opt to stop the procedure if
there is any discomfort
• Gain Consent
Palpation
• Ensure a chaperone is ● Lubricate the finger
present (especially if Male ○ Use the Index Finger
Gynecologist) ● Insert the finger gently into the anal canal
○ Gloves
○ Lubricant
○ Paper Towels
○ Cervix
○ Adnexal area
• Inspection
• Palpation
and assess
○ Blood
○ Stool
○ Mucus
patient
• Wash Hands
assessment

● From the pelvic exam, gently douglas)
slip the middle finger to the
rectum while the index
Nodularity
finger remain in the Tenderness
vagina
● Insert the finger in the full Masses
length of the vagina . For the rectal finger, palpate the integrity of the rectal mucosa and presence of
● Palpate the tissue in between mass.
the rectum and the vagina
(rectouterine pouch of Rectal Mass
douglas) ○ Palpate for
nodularity,
● For the rectal finger, palpate
the integrity of the rectal
mucosa and presence of
mass.
● Example:
○ A patient with an enlarged
ovary wherein we cannot
examine
inconclusive results from the
vaginal exam ● Index finger is
inserted into the vagina, and
the Middle
finger is inserted into the
rectum (anal opening)
● Generally:
○ Vaginal Exam, Rectovaginal
Exam and Rectal exam will not
do harm in a pregnant patient
identified in patients with
pelvic organ
prolapse.
gynecological exam with a
vaginal exam (not appreciated
enough with IE)
○ You can sweep your finger at
the back of the uterus, to
palpate uterosacral and cul de
sac area
○ For ovarian cysts that is
toward the back
▪ unlike in lateral ovarian cyst
that is appreciated on IE
SALIENT FEATURES
Age: 22 Vital signs were all normal except: 150/90

OB Score: G1P0 (0000) / primigravid, 37-38 weeks BMI 18.9
Nulli/multi: Systemic pe: unremarkable except:
OB score:
Abd: globular, striae, no scars, FH 33 cm; LM 1 buttocks, LM2
NSD/CS
Single/married: live in partner fetal back left, LM3 cephalic; FHT 130
Religion: Catholic
Occupation: Housewife Contractions moderate occurring every 5 minutes, 30s long
CC: Follow-up Prenatal care, but patient also experienced
- Start: 4 months Pelvic exam:
- 4th prenatal check up
- Normal
External genitalia: inverted triangle pattern; no lesions
- UTZ: 1st check up at 4 months
- AOG 37-38 Internal examination showed: Cervix,soft, long, closed, posterior
in location, intact membranes, floating head
Uterine/abdominal Contractions (hardening): (Regular contraction but no dilatation & effacement - consider
- 3-4x per hour since early morning early labor)
- (+) fetal movements
Bishop score 2
Medications:
Methyldopa (Aldomet) 500mg BID Extremities
● 130/90 ; 140/90
● Gestational HTN (35 wks AOG), no proteinuria PE:
● Compliant Labs:
FeSO4 (Hemarate) OD
No GDM (by OGTT)
FX: Father (htn), maternal aunt (DM)

Risk factors:
Symptom:
● Painless vaginal bleeding
● No dysmenorrhea, no
G1P0 primigravid Pregnancy uterine at 37-38 weeks AOG, Cephalic, t/c early labor, Preeclampsia with severe features
Signs and Labor initiation: 12x /hr

Symptoms Every 2-3 mins lasting for 50-60 secs ung adequate
Physical
examination
Diagnostic/ * If need surgery, don't forget to request for cbc, blood chem, pt/ptt etc. and COVID-19 rt-pcr swab test!
ancillary (make
sure to request
CBC w/ platelet
for labs that will
be - Check if there's thrombocytopenia (possible preeclampsia)
cost-effective) Urinalysis
- 24 hr urine protein
BT
HbsAg
COVID-19 RTPCR

(Include
therapeutic and
preventive;
management Management: check yung admitting ordersss
goals;if kaya Labor room??
gawing specific
like dose etc) ● Admit to LABOR and Delivery ROOM (LRDR)
○ Term
○ Uncontrolled HTN
○ Moderate contractions
● Request for COVID swab
○ Negative
● Monitoring of uterine contractions progression and cervical dilation and effacement
● EFM help
● Modified bed rest
● Monitor VS every 30 mins and record
● Diet: NPO until further order, or px is stabilized
● Activity
● Monitor:
● Investigation:
○ CBC repeat
○ Stat Urinalysis
■ +3/+4 proteinuria - progressing to pre-eclampsia
■ If neg - do 24 hr urine protein
○ Liver transaminases? LDH - to rule out organ dysfunc and r/o progressive to severe features
○ Serum creatinine
● Therapeutic
○ IV fluids usually D5NR 1L 20-25 drops per min.
■
○ Nicardipine drip - control bp
■ Target:140/90, gradually lower
■ It may dec hypoperfusion → hypoxia to fetus → placental blood flow -> hypoperfusion
→ uteroplacental insuff → sudden fetal demise
■ Before, insert IV fluids (any fluid but NSS if BT is anticipated)
○ Anesthesia: epidural (less effect on hemodynamics)
○ MgSO4 (4g IV for 20-30mins, then 1-2g/hr IV slow infusion or 4:5:5 - seizure protection
■ Baseline: Urine output (ask when last urinate and amount <30), RR (<12), DTR(+2
patellar reflex)
■ ACT: Because she has headaches
○ Give steroids for lung maturity to reduce chances of RDS (FOR PRETERM ONLY BUT FOR
THIS PATIENT NO NEED NA)
Plan:
● Observe and monitor until labor
● Know the CTG tracings
○ (+) contractions every 5 minutes, moderate to strong, 40-50 seconds duration
○ FHT 140-150
○ Minimal variability
● Reassuring → continue with labor
● Cervical Ripening with Dinoprostone (prostaglandin E2) - contraindicated! For HTN and for
asthmatic patients , and HTN (might also aggravate hypertension) oxytocin?
● Laminaria
● Then Labor Induction
Scenario:
BP continuous 160/100
Uterus was contracting every minute and was hardening - Tachysystole, decelerations
● Abruptio placenta (clinical impression, no need for utz)
● Emergency CS delivery since cervix is still closed
○ Structure seen after muscle-: amniotic membranes/fluid (since intact membranes no watery
discharge)
■ Possible color with detachment: red (port wine staining)retroplacental clot behind
■ If early detachment may still be clear
○ Retroplacental clot
Postpartum:
● Stop methyldopa within 2 days after birth
● Change to CCB
LAT- labor admission test (LAT) implies that a cardiotocography (CTG) of 20–30 minutes duration is done at
admission to the labor ward.
- Procedure we do with EFM on admission of pregnant woman in labor, to know if fetus can handle stress
of labor
- Result: Reassuring
NST
- antepartum surveillance test; not done during labor
- to check fht of baby, if there are any accelerations and decelerations in relation to fetal movement (must have
10-15 accelerations)
OPD HTN:
● Methyldopa PO
○ Methyldopa (Aldomet) 500mg BID
● Nifedipine PO
Hypertensive crisis:
● Nicardipine IV
● labetalol (books)
● hydralazine (not avail)
Preventive:
Based on Chief Complaint: Vaginal Discharge
Differentials Braxton Hicks

Contraction
Signs and Symptoms - Irregular and

infrequent
Reason for R/o?
Management

D G1P0 (0000), Pregnancy, uterine at 37 weeks AOG, Placenta Previa
D NPO until further order
I Request for: CBC, blood-typing, antibody screen, cross-match, stat urinalysis +3/+4 on
protein/ 24hr urine protein, AST/ALT, LDH, SCr

Topic
Facilitator LNR
Clerks Hao, Caitlin and Heredia, Gabrielle
Date 23 August 2021
HISTORY

ko na po.
General Data Name: CT

Age > 35 (risk factor for Previa, Age: 28
Abruptio) Birthdate:
Birthplace: Mindanao
Address: Quiapo
Marital Status: Married
Nationality: Filipino
Religion: Islam
Occupation: CD/Phone accessories saleswoman (finished 3rd yr
college)
● Chief Complaint: Ano po

ang rason kung bakit po
kayo nagpa-konsulta *pagkaask if alam kung buntis and yes, jump to LMP to know lang AOG
ngayong araw? (based on ESGD with mongon) - bago pa po tayo tumuloy, tanong ko
● If answer is related to lang po yung unang araw ng huling regla ninyo para lang po malaman
pregnancy: ask if alam kung gaano na po katagal ang pagbubuntis ninyo.
niyang buntis siya and if
nag pregnancy test na
● First time ninyo po ba
magpa-konsulta? Kung
hindi first time, tanungin
kung anong diagnostic
at lab na pinagawa and
result?
History of Present CC: Bleeding
Illness:
O: Kailan po ninyo unang Onset: Last week
napansin? Location:
D: Gaano katagal kapag Duration:
dinudugo kayo? Tuloy-tuloy po Character: 1 napkin a day, biglang lumakas today, kumikirot
ba ang pagdudugo? Aggravating:
C: Masakit po ba? Marami po Alleviating:
ba? Relieving:
- Abruptio (painful) Temporality: on and off
A: May ginawa po ba kayo Severity: 4-5/10, Today: 8
anung napansin ninyo yung
pagdudugo niyo?
A: May iba pa po ba kayo Ask for Danger signs of pregnancy
Dysmenorrhea? Paghihilo? Y/N Meron po bang pagsakit ng ulo
Pamumutla? Y/N Panlalabo ng mata
R: May ginagawa po ba kayo Y/N Hindi nawawalang pagsusuka
dito para mawala? Y/N Lagnat at panginginig ng katawan
S: If masakit, gaano kasakit? Y/N Pamamanas ng kamay at paa
Pwede niyo po bang i-rate from Y/N Sakit sa tiyan
1-10, 10 po ang pinakamasakit Y/N Napansin po bang pagbabago sa paggalaw po ni baby? Nabawasan
po ba?
May mga gamot po ba kayong Y/N Sakit sa pag-ihi o hirap sa pag-ihi
iniinom ngayon? Mga iron? Folic Y/N Meron po bang matubig o madugong lumalabas sa pwerta
acid? Calcium?
● Blurring of vision, headache, convulsions, edema of hands and
feet (preeclampsia)
Ask for previous check ups and lab results
LMP: last week of May
May (31-26= 5)
June (30)
July (31)
Aug (23)
AOG : 12-13 weeks
M-
I-
D-
A-
S-
() Weight Changes
() Changes in appetite
() Fever
() Malaise
() Sleep Changes
Breast:
() Masses
() Discharge
() Tenderness
() Nipple Changes

Skin:
() Change in color
() Itchiness
HEENT:
Pulmonary:
() Cough
() Wheezing
Cardiovascular:
() Chest Pain
() Palpitations
() Leg swelling
Gastrointestinal:
() Nausea
() Vomiting
() Abdominal Pain
() Dysphagia
Genitourinary:
() Dysuria

() Joint swelling
() Weakness
() Headache
() Syncope
() Memory loss
() Polydipsia
() Polyphagia
() Polyuria
magalit)

●
asthma, TB, sakit sa thyroid, PCOS, ●
ninyo kasama po ng pagkakaroon ●
o kaya pagdami po ng mga ●
ultrasound para po sa obaryo
●
ninyo?)
Immunizations:
○ Gout: masakit po ba ang
● Flu
kasukasuan?
● Covid
● Past hospitalizations/surgeries: ● (-) HPV
Naospital na po ba dati? Naoperahan na
po ba dati? Current Medications/Supplements:
○ Always ask year, reason for ● Generic Name:
operation, any complication? ● Brand:
● Injuries/ Accidents: May mga accidents ● Dose:
po ba dati na nainjure kayo? ● OD/BID:
ng dugo? Allergies:
● Immunizations: Nabakunahan na po ba ● Antibiotic
laban sa cervical cancer o HPV vaccine?
wala?
or labs
resulta?
po bang bukol?
Family History: Grandmother: diabetic

DM, HTN, CA (breast, cervical, Father:
endometrial, ovarial), asthma, heart Mother: htn
diseases Siblings:
PCOS and other Other family members: Lolo(?) - cancer
genetic gyne disease
None
Personal and Social History:
Diet: Fish
Activity Level/Exercise: No
Smoking: No
Alcohol Intake: No
Illicit drug use: No
OB-GYNE History
Menstrual History: Menarche (kelan unang niregla) :

Interval (pagitan 1st and last):
● Only ask if unsure if pregnant?? Duration (ilang araw nag reregla): 3-4days
Amount (gaano kadaming napkin ang nagagamit, anong
klaseng napkin po ang gamit? Regular or yung night):
3-4 regular napkins a day - soaked
Symptoms: dysmenorrhea? other symptoms?
First day - dysmenorrhea
● G: tanong ko lang po kung Ilan po ang Gravidity:

lahat ng pagbubuntis ninyo, at kung sakali
Parity:
po ilan po dito ang nakunan?
G1 18y/o (Year):
● Iisa lang ba ang ama sa lahat?
● BB boy/girl?
○ Yung unang anak niyo, kailan
pinanganak? ● AOG
○ Babae o lalaki? ● BW
○ Naka-ilang buwan po siya nung ● NSD or C/S
pinanganak? Husto po ba? ○ Indication:
○ Naalala niyo po ba yung timbang ● Where:
at haba po ni baby ● Complications:
pagkapanganak? G2 19 y/o
○ Normal po ba ang panganganak o
G3 22 y/o
cesarean po?
LMP: (natatandaan nyo pa po ba yung huling regla
ninyo? Kelan po yung unang araw?):
midwife? PMP:
Nasabi niniyo kanina How frequent is the Prenatal Check-up?
Laboratories done: all normal
● CBC
● Urinalysis
● FBS OGTT
Medications:
Part of the ‘History of Present Pregnancy’ if no
complaint. This will be the last part of HPP.
A separate entry if (+) complaint
Always ask for the ff information every PNCU (PreNatal Check
Up): Signs & symptoms experienced by the patient
Iron supplement
Calcium
Immunizations:
Tetanus Toxoid
Hepatitis B
Influenza
Pneumococcal
CBC, platelet count
Blood typing
HBsAg
VDRL / RPR
HIV Testing

History of discharge?
Vulvar itchiness?
Ulcerations?
Warts?
Pap smear with dates and results (last year, normal findings)?
Sexual History Pasensya na po medyo sensitibo pero need ko po malaman para makatulong sa
- Only ask if inyo..
needed talaga
since ayaw to Coitarche:
tinatanong ni No. sexual partner/s:
doc mongon Occupation of Partner/s:
- To know risk Regularity: (Gaano po kadalas)
for cervical Associated symptoms: none (dyspareunia, bleeding)
cancer (sex at Date of last sexual contact:
around teens
and no HPV
vaccine) Type of contraceptive used:
• Important to ask the Generic/brand name:
o ex. call center agent: high
Duration of use:
risk for STD Reason for choice
• Elicit promiscuity of patient Satisfaction with method:
(risk factor for STDs like HIV)
PHYSICAL EXAM
General Survey The patient is conscious, coherent. Is she ambulatory?

Mental Status:
- Conscious, coherent,
Vital Signs BP:

● Pre-pregnancy:
● Current: 110/80
HR: 85
RR: 20
Temp: 37

Weight (Pre-preg): 110lbs
49.9kg/(1.57x1.57) = 20.2
50.3 / (1.57x1.57) =
BMI (Prepreg): 20.2

BMI (Current): 20.3
HeadEyesEarsnNoseThr
oat ● Pink palpebral conjunctiva
● Gum bleeding?
● Neck masses?
Lungs INSPECTION
AUSCULTATION
Clear breath sounds

● No murmurs
Breast Before starting I would ask for consent
If pertinent?
Inspection
• Wash hands
Any gross abnormality on the breast?
• Confirm patient details (Asymmetry
• Explain Examination Before assuming asymmetry, always ask if it is always have been asymmetrical
• Gain Consent The dominant side usually appear larger than the other side
present o Male gynecologist Swelling
a
Masses
female assistant Skin Changes
• Expose patient
Nipple Changes
o Thank Patient Pressing into hips
o Wash Hands (Contraction of Pectoralis Major)
recommended once a month Hands behind head )
after o Push elbows back and lean forward (will exacerbate skin dimpling)
menstruation
▪ Hormone has less effect in
the breast
Asses:
physician) breast exam once Swelling?
a year
Mass?
pap smear Location
diagnostic o If biopsy is needed, Size/Borders
breast CA = request
Fixation
• Non-palpable lesions can be
detected in mammography
Abdominal <28 weeks
Inspection: Flat or globular?slightly glob Presence of striae, scars?
Auscultation: bowel sounds: normoactive?
Palpation: Direct/Rebound tenderness? hypo
Fundic Height:
○ 12 weeks: fundus at the level of the symphysis pubis
○ 16 weeks: midway
○ 20 weeks: umbilicus
>28 weeks
1. Auscultation: FHT= ______ bpm located on the ______________,
note for regularity.
2. Palpation: Fundic Height = cm EFW= _____kg
3. Leopolds Maneuver (highlight answer in bold)
LM1 (Fundal Grip)


- Cephalic presentation is not engaged: movable, round, hard body
palpated
- If lower pole of fetus is engaged, head is fixed.
LM4 (Pelvic Grip)

Engaged or not?
Extremities Full and equal pulses?

First, ask the patient to void
Pelvic Exam External Genitalia; Inspect the Vulva

● Lesions
IE - don’t do if ● Scars
bleeding in the ● Erythema
second half of ● Discharge
pregnancy!! ● *Pubic Hair Distribution
Ask to empty bladder - inverted triangle pattern
Introduce yourself
o Patient’s name and date of
pregnancy Check patient’s
o Explain that light vaginal
to accompany you
Gain consent
mass, prolapse and

used o Gloves
o Speculum
o Lubricant
o Sample Pot
used)
Speculum Exam
● Inspect the Cervix:
● Speculum Exam ○ Color: is it violaceous, smooth?
- Hold the handle ○ Discharge (amount, color, description):
of the speculum ○ Gross lesions?
with your ○ Shape of external os:
dominant hand, - parous cervical os (fish mouth) or
and - nulliparous cervical os (circular)
● open the labia
minora with the
other one (use
thumb and 5th
finger). Insert the
CLOSED
speculum gently,
sideways at first,
then slowly rotate
to the normal
position, then
gently open the
speculum. Inspect
the cervix.
INTERNAL CERVIX:
EXAMINATION (IE) ● Soft, long, closed? 1cm dilated
● No abnormal nodule or masses?
Don’t do if the vaginal ● Cervical motion tenderness?
bleeding is on the
second half of UTERUS:
pregnancy ● SKIP
Bimanual Exam
ADNEXAL:
● No adnexal masses nor tenderness

• Rashes
virgin or has no sexual history. • Hemorrhoids
Do not do
vaginal exam given those • Anal Fissure
indications
• Bleeding
• Confirm patient details • Fistulae
• Abscesses
quick examination
opt to stop the procedure if Palpation
there is any discomfort ● Lubricate the finger
• Gain Consent ○ Use the Index Finger
present (especially if Male ● Insert the finger gently into the anal canal
Gynecologist)
○ Gloves
○ Lubricant
○ Paper Towels
○ Cervix
○ Adnexal area
• Inspection
• Palpation
and assess
○ Blood
○ Stool
○ Mucus
patient
• Wash Hands
assessment
Nodularity
vagina
nodularity,
mass.
● Example:
examine
the Middle
● Generally:
pelvic organ
prolapse.
enough with IE)
sac area
toward the back
SALIENT FEATURES
G4P3 (3003) -VS normal

CC: Bleeding, intermittent (since last week, 1 napkin/day) -BMI 20.1 (normal)
- Today: sudden gush (stronger)
(+) pregnancy test
Abdomen:
Associated Sx:
● Pain ● I: Slightly globular, (+) striae
○ 1 week ago: 4-5/10 ● A: Normoactive
○ Today: 8/10 (severe dysmenorrhea-like) ● P: (+) direct tenderness on the hypogastric area, fundic
● No pallor height at level of symphysis pubis
● No fever
● No edema Pelvic:
LMP: May 24-28?, 2021
● Inspection: no erythema, scars, discharge; inverted
- Assuming^ AOG: 13 weeks AOG by LMP
triangle
May contractions ba siya di ko narinig if natanong ● Speculum: cervix is violaceous, smooth with bleeding
Paang hindi natanong coming out of the internal os; no gross lesions
No hypertension, no DM ● Internal: cervix is soft, 1 cm dilated, no cervical motion
tenderness; no adnexal mass;
FX: Mother DM
Age:
Nulli/multi: Vital signs were all normal except:
OB score: Systemic pe: unremarkable except:
NSD/CS No (pertinent negatives) ___________
Single/married: External genitalia: inverted triangle pattern; no lesions
Religion: Speculum exam revealed:
Occupation:
Internal examination showed:
CC:
Risk factors:
Symptom: PE:
● Painless vaginal bleeding Labs:
● No dysmenorrhea, no
G4 P3 (3003) Pregnancy uterine at 13 weeks AOG by LMP, Probable Inevitable Abortion
Signs and
Symptoms
Physical
examination
Diagnostic/ Transvaginal utz: to know the viability of the pregnancy, location, number
ancillary (make - Complete: minimally thickened endometrial lining w/o gestational sac
sure to request - Incomplete: evidence of placental tissues still seen within endometrial cavity
for labs that will - Inevitable: live, intrauterine pregnancy
be - Rule out other differentials
cost-effective) - Check location of pregnancy
- Live intrauterine pregnancy, located at LUS 8-9 wks AOG, good cardiac activity
- Both ovaries are normal
- CBC hgb: 10, hct 30 , WBC 8000
- Urinalysis: pus cells 20-30/hpf
Ferrous sulfate - PO
CBC- to establish baseline hgb, hct bc bleeding

● Hematologic status since she presented with bleeding
● Patient: hgb 10, hct 30, WBC 8,000 (low hgb
FBS
- 3.8 mg/dL
● History of diabetes
● FBS 3.8
Urinalysis
● Check for asymptomatic bacteriuria
● Px: Pus cells 20-30 /hpf
Blood typing
- Possible blood transfusion in the future
- A positive
- Rh positive blood type A
Ferrous Sulfate, Oral

IV Iron
- Ferric Carboxymaltose
- Increases hemoglobin rapidly than IV iron sucrose
- Administer once
* If need surgery, don't forget to request for cbc, blood chem, pt/ptt etc. and COVID-19 rt-pcr swab test!

Urinalysis: screening for asymptomatic bacteriuria
crown rump length (CRL).
● (Example of a report: TVS showed a single live intrauterine pregnancy, 12-13 weeks AOG by CRL, with
good cardiac activity.)
- Yolk sac: 5 weeks
For AOG:
- Fetal biometry - >13 wks (14-26 weeks) (biparietal diameter, femur length, abdominal circumference,
head circumference)
- BPS
- Fetal tone
- 10x every 2 hours
- Fetal breathing
- Reactive fhr: 2 or more episodes of acceleration of >15 bmp and of >15s associated
with FM within 20 mins
- Contraction

(Include
therapeutic and
preventive; Management:
management ● Admit patient
goals;if kaya ○ There’s live pregnancy that can be saved
gawing specific ○ To monitor since patient is bleeding
like dose etc) ● RT-PCR
○ r/o covid
● Antibiotics
○
Preventive:
Based on Chief Complaint: Bloody Vaginal Discharge
Differentials Abortion (incomplete Ectopic Pregnancy Molar Pregnancy Incomplete Abortion

vs complete)
Signs and Symptoms a. No longer a. Classic Triad ● Nausea + vomiting Bleeding
Hypogastric pain
experiencing the i. Missed menses (hyperemesis
symptoms of ii. Pain (sharp, gravidarum)
pregnancy, such as stabbing, or ● Uterine growth
feeling sick and tearing) more rapid than
breast tenderness iii. Minimal vaginal expected
b. Vaginal bleeding bleeding or ● Pelvic pressure or
c. Hypogastric pain spotting pain
(Incomplete, (decidualization of
complete, +/- endometrium is ● Uterine size
missed, +/- not maintained by greater than
threatened) hormones thus gestational age
d. Passage of meaty spotting LANG) ● Soft, boggy uterus
tissues b. Passage of tissues ● Missed menses
(Incomplete and or decidual casts (1-3 months of
complete (Entire sloughed amenorrhea
aboprtion) endometrium that typically)
e. Gross rupture of takes the form of ● Irregular bleeding
membranes the endometrial (ranging from
(Inevitable cavity) spotting to profuse
abortion) hemorrhage)
f. Closed cervix c. In cases of an ● Passage of
(Threatened, unruptured grape-like, cystic
complete, and ectopic pregnancy molar tissues
missed abortion) i. Uterus slightly “parang sago”
g. Dilated cervix enlarged ● Moderate
(Inevitable and ii. (+) Adnexal mass iron-deficiency
Incomplete cervix) iii. Tenderness on anemia
palpation of the ● Ovarian theca
lower abdomen lutein cysts
and adnexa ● Hyperthyroidism
iv. Cervical motion
tenderness
d. In cases of a
ruptured ectopic
pregnancy
i. Severe lower
abdominal pain
(sharp, stabbing,
tearing)
ii. Generalized
tenderness upon
abdominal
palpation
iii. Cervical motion
tenderness
("wiggling
tenderness”)
iv. Bulging posterior
fornix/cul de sac
(because of
hemoperitoneum)
v. Tender boggy mass
may be felt beside
the uterus
vi. Signs of
diaphragmatic
irritation
● Neck or shoulder
pain, especially on
inspiration due to
sizable
hemoperitoneum
vii. Signs of peritoneal
irritation
● Direct/rebound
tenderness,
board-like rigidity
all point to an
acute abdomen
secondary to a
tubal rupture
iii. Signs of
hemodynamic
instability when
hypovolemia
becomes
significant
● Hypotension
● Tachycardia
● Pallor
Reason for R/o? No passage of meaty

tissues
Management

DISCUSSION
Salient features y/o, G P ( ), weeks AOG
CC: “ ”
hours PTC, had
FHT /min
Fundic Height: cm
Leopold’s Maneuvers
● LM1 -
● LM2 -
● LM3 -
Violaceous cervix with minimal bright red bleeding from the os
Clinical Impression G P ( ), Pregnancy uterine, weeks AOG, presentation, trimester

bleeding to consider ?
Ddx
First loop notes (Sept):
First loop notes

(July Group)
Diagnostics and Work -
Up
Final Diagnosis
Management
Prevention

Concerned more of FHT, FH, Leopold’s maneuvers, in 32 weeks AOG than the bowel sounds Give first
impression and formulate plan of treatment

Can occur in primis

Age
Multiparity
CS delivery
HPN
Prior Abruptio
Trauma or accident
Prior history of trauma to endometrium (hx of curettage, hysteroscopy of submucous myoma) **but this
patient no previous surgeries or trauma
General comments:
● Be more focused
● Ideally, 3rd trimester bleeding and thinking of Placenta Previa refrain from doing IE and go for
ultrasound
● Missed in hx:
NOTES FOR CARES

GENERAL DATA
NAME: BD AGE: 28
DATE OF BIRTH: QC NATIONALITY: Filipino
PLACE OF BIRTH: QC RELIGION: Catholic
ADDRESS: QC EDUC ATTAINMENT: HS
CIVIL STATUS: Married for 5 yrs OCCUPATION: Housewife
YEARS MARRIED: 5 yrs CONTACT NUMBER:
SUBJECTIVE
CHIEF COMPLAINT: Vaginal bleeding for 3 days
HPI:
● ONSET ● 3 days ago

● LOCATION/ RADIATING PAIN ● -
● DURATION ● -
● CHARACTER ● Humihilab
● AGGRAVATING ● -
● ASSOCIATED FACTORS ● (+) dysmenorrhea for 3 days
● RELIEVING FACTORS ● None
● TEMPORAL FACTORS ● Di napupuno yung napkin
● SEVERITY OF SYMPTOMS ● (severity not asked)
LMP: June 25-29

PMP: May 23-27
Weeks of Gestation: 8-9 weeks

Expected Date of Delivery: April 2, 2022
Previous Prenatal Check-ups: (if applicable)
Course in the Delivery Room: (if applicable)
OBSTETRIC HISTORY
GRAVIDA: 2 PARA: 0 TERM: 0 PRETERM: 0 ABOR: 1 LIVE: 0
DATE (ex) delivered to a live term baby boy (BW 4kg) via NSD at a lying in
clinic in Manila, no complications
G1 - 2020 Ectopic pregnancy, R, 8 wks AOG, Salpingectomy, no complications,

USTH
G2 -
G3 -
MENSTRUAL HISTORY
M: 13 y/o I: regular D: 4-5 days A: 3 regular Sx: (-)

pads/day, dysmenorrhea,
moderately headache
soaked, no
clotting
NAUSEA/VOMITING (yes or no) slight
HEADACHE/DIZZINESS(yes or no) no
VISUAL DISTURBANCE(yes or no) none
EDEMA (yes or no) none
URINARY OUTPUT No difficulty in urination
BOWELS
VAGINAL BLEEDING
Other ROS No change in weight

No cough and colds
Cough, colds, sore throat, chest No SOB
pain, dyspnea, easy fatigability, No easy fatigability
dysuria, polyuria, nocturia, edema,
joint pains
*input here*
PAST MEDICAL HISTORY No HPN
Htn ( ) DM ( ) Thyroid disease ( ) No DM
asthma ( ) allergies ( ) previous No Asthma
hospitalizations ( ) Previous No allergies
surgeries ( ) history of blood
transfusion ( ) injuries ( ) Hospitalizations ectopic only
medications ( ) and
immunizations ( ) COVID immunization
Flu - none
25 y/o
2 sexual partners (office workers)
SEXUAL HISTORY 1-2x a week
No s/s
Kelan po ang unang beses na No fam planning
nakipagtalik? ( )
(+) PT last week
Ilan po yung naging sexual
partners? ( )
Ano po trabaho ng partner? ( )
Gaano kadalas? ( )
Meron po bang masakit pag

nakikipagtalik? ( ) O pagdurugo?
( )
Ano po ang ginagamit nyong

family planning method? ( )
(-) none
FAMILY HISTORY
Meron po bang may hypertension

sa pamilya? ( - )
DM ( -) asthma ( - ) thyroid ( - )
cancer ( - )
Covid vaccine - 2 doses

PERSONAL AND SOCIAL
HISTORY
Smoking ( - ) alcohol (-)

gumagamit ng ipinagbabawal na
gamot (-)
Complete po ba vaccination nyo?

Covid, flu, tetanus
OBJECTIVE
VITAL SIGNS
BLOOD PRESSURE 110/80
PULSE RATE 80
RESPIRATORY RATE 20
TEMPERATURE 36.5 C
OXYGEN SATURATION
HEIGHT Ano height?
WEIGHT (PRE-PREG) 130 lbs
WEIGHT (CURRENT) 130 lbs
SKIN No active dermatologic lesions
HEENT Pink palpebral conjunctiva, anicteric sclerae, no neck

mass
CARDIO Adynamic precordium, regular, no murmurs
PULMONARY Symmetrical chest expansion, clear breath sounds
BREAST Symmetrical breasts, no skin lesion, no palpable mass,

no skin dimpling, no nipple discharge
ABDOMEN
(+) Transverse suprapubic incision (Pfannensteil

incision)
Globular
No mass, no tenderness
Normoactive bowel sounds
FETAL ASSESSMENT -skip

8 weeks pa lang
FUNDIC HEIGHT
As early as 16 weeks; should
coincide with AOG
PRESENTATION
Leopolds start at 28 wks
LM1: BREECH
LM2: FETAL BACK RIGHT/LEFT
LM3: CEPHALIC
ENGAGEMENT
POSITION
FETAL HEARTBEAT
N= 110-160
Earliest at: 5-6wks via TVS
Doppler: 10 wks
Steth: 18 wks
Hair distributed in moderate amt, inverted triangle

NO skin lesion, no masses
EXTERNAL GENITALIA NO episiotomy scar
Ex. Hair distributed in an inverted Labia apposed to each other
triangle, no gross lesions, scar
Cervix smooth, violaceous with minimal bleeding

SPECULUM EXAM coming from os
Ex. Cervix violaceous, soft, with
minimal non foul mucoid
discharge
Cervix is firm, long, closed

No cmt
INTERNAL EXAM Slightly enlarged, movable
Ex. Cervix is firm, long, closed, Non tender
no cervical motion tenderness Soft uterus
Uterus enlarged by (weeks), (-) adnexal mass nor tenderness
anteverted, movable, nontender/
soft/boggy
No adnexal mass, No tenderness
ASSESSMENT
This is a case of BD 28 yo, G2P0 (0010) 8-9 wks AOG who came in the OPD with chief
complaint of vaginal bleeding which started 3 days ago. This is accompanied by crampy pain on
hypogastric area. Patient had a positive pregnancy test
Prenatal check-ups:
PE:
SALIENT POSITIVES SALIENT NEGATIVES
● 28 year old, married (5 years) ● No dysmenorrhea, blood clots

● G2P0 (0010) ● No danger signs of Pregnancy
● 3 day history of Bleeding, with ○ No headache
intermittent cramps ○ No fever
● Missed menses: 8-9 weeks AOG ○ No blurring of vision
(LMP June 25-29) ○ No edema
● History of ectopic pregnancy (8 ○ No dyspnea, easy fatigability
weeks AOG); Salpingectomy ○ No dysuria
● Slight nausea and vomiting ● No weight change (130lbs)
● (+) pregnancy test ● Unremarkable family history
● BP 110/80 ● No jaundice or pallor
● HR 80 ● Unremarkable HEENT, cardiac,
● RR 20 respi, breast PE
● Transverse suprapubic scar ● Abdomen no mass no tenderness
(Pfannenstiel) normoactive bowel sounds
● Cervix violaceous, smooth, ● External exam: Inverted triangle
minimal bleeding per os pubic hair, no lesions, no mass
● Uterus slightly enlarged, movable, ● Cervix firm long closed
non-tender, soft ● No cervical motion tenderness
● No adnexal mass or tenderness
RULE IN RULE OUT
DIFFERENTIALS
1. Spontaneous Abortion Bleeding with pain in the 1st half RF not present:
(I think threathened of pregnancy - history of infections
abortion) sameeeee + Pregnancy test - Smoker
+ hypogastric pain - Uterine size slightly
Globular abdomen enlarged (threatened
Violaceous cervix (Chadwick) dapat compatible with
Closed cervix AOG)
2. Ectopic Pregnancy TRIAD: missed menses, No adnexal mass and

abdominal pain, spotting tenderness
Bleeding with pain No hx of PID(but still can’t say
Previous history of ectopic she has no PID bc it can be
pregnancy asymptomatic)
Prior tubal surgery
Violaceous cervix
(+) Pregnancy test
3. GTD? Bleeding on 1st half of No grape-like cystic molar

pregnancy tissues
38 yrs old (36-40 are at 2x risk)
Missed menses
Irregular bleeding
+ preg test
Uterus larger than AOG
4. Ovarian Torsion Abdominal pain Acute severe unilateral pain

No mass
(-) vomiting, nausea
(-) adnexal mass, no tendernes
5. Cervical Polyp Bleeding
6. AUB-A Bleeding with pain (-) progressive dysmenorrhea
CLINICAL IMPRESSION
G2P0 (0010) 8-9 wks AOG by LMP , t/c ectopic pregnancy vs threatened abortion
Basis for Diagnosis:
Ectopic:
Triad of missed menses, abdominal Pain, bleeding/spotting
Highest risk factor: previous ectopic
Threatened: bleeding in 1st half of pregnancy

Cervix closed
PLAN
ANCILLARY AND LABORATORY PROCEDURES
1. Transvaginal Ultrasound: confirm pregnancy, AOG, location and number of fetus

2. CBC: Determine hematologic status, and assess the physiologic anemia of pregnancy (due to
hemodilution from increased intravascular volume): Normal lahat
a. Hgb 12
b. Hct 33 -
c. WBC 6
d. Platelet 180
e. Blood typing O+
3. BT with Crossmatching: ABO incompatibility, for possible blood transfusion kasi
maguundergo surgery
4. Urinalysis: Rule out infection -asymptomatic bacteriuria
5. FBS
UTZ
- Gestational sac
- With yolk sac (sac w/ ring-like structure) -> - tells you that intrauterine pregnancy
- Unusually large w/ no fetus - blighted ovum/ anembryonic pregnancy -
explain why uterus is larger than AOG
- With this you rule out ectopic pregnancy
MANAGEMENT
Acetaminophen-based analgesia (paracetamol) will help relieve discomfort from cramping
Follow up: (since <26 weeks) after 4 weeks
Expectant management - Blighted ovum

● Watchful waiting
● Advise bed rest
● Follow up in 2 weeks (Repeat TVS)
○ Fetal structures should be seen by this time
○ If still anembryonic after the expectant management: D&C
■ Insert laminaria (24 hours) so that cervix will dilate → the next day,
proceed to curettage
If did not expel on it’s own then next step is Evacuation
● If not expelled in 2 weeks
● Insert laminaria for 24 hours to dilate
● Next day, do the completion curettage
Counseling for next pregnancy
● Inform patient that subsequent pregnancies may be high risk
● Work-up: detect for any causes of abortion like DM, HPN, APAS
● If chromosomal - advice not to get pregnant
Final Dx: G2P0 (0010) Blighted Ovum 8-9 wks AOG
MTD COMMENTS: ask intensity of pain, check position of uterus (important when doing
curettage) , assess cul de sac especially if dealing with ectopic(shallow or deep-
indicative of possible hemoperitoneum), ask regarding extremities
Missing data:
● Intensity of pain
● Position of uterus
● Cul de sac - imp esp if ectopic preg
○ Shallow or bulging - tell if there is hemoperitoneum
● Extremities
● Incompatible AOG
○ Early preg (wrong dating)
○ Abnormal preg (blighted ovum)
○ Ectopic preg
● If with yolk sac, IUP na ito, cannot be ectopic
FOLLOW-UP CHECK UP
1st check-up- 28wks: every 4 weeks
28 wks-36 weeks: every 2 weeks
37 weeks onwards: weekly
ADMITTING ORDER - Admit Diet Monitor

Investigation/Intervention Therapeutics
ADMIT
DIAGNOSIS
CONDITION
VITALS
ACTIVITY
NURSING ORDER
DIET
IV FLUIDS
MEDICATIONS
LABS
CALL HO
DIFFERENTIALS
DDx 1 DDx 2
CC: MISSED MENSES
DEFINITION
RISK FACTORS
SIGNS/SYMPTOMS
ANCILLARIES 1. CBC
2. Blood typing
3. Urinalysis
4. FBS
MANAGEMENT 1. Nutrition and

counselling
a. 25-35 lbs gain
b. Calorie intake
2. Multivitamins
(Clusivol) 1 tab per
day
3. Ferrous sulfate ??
4. Folic acid 5mg/ tab
#30 1 tab od for 1
month
5. Calcium 30g, 1 tab
od?? Calcium
carbonate 500mg
3x(?) a day
6. Immunizations
DDx 1 DDx 2 GGx

SPONTANEOUS ECTOPIC Molar
CC: 1ST TRI ABORTION PREGNANCY
BLEEDING
DEFINITION Implantation of
blastocyst in areas
other than the
endometrium
RISK FACTORS Uterine size, cervix Prior tubal surgery Extremes of age
close/dilated Previous ectopic (adolescent, >40)
Infection Hx of molar preg
Age >35 Smoker Race
Obese Post op adhesions
Smoker
DM/thyroid
Infection
Previous surgical
SIGNS/SYMPTOMS Vaginal bleed Missed menses, Missed menses

Hypogastic pain hypogastric pain, Uterine bleeding
spotting (TRIAD) Grape-like tissue
Tender abd
Cervical motion
Ruptured: rebound
tenderness, cervical
motion tenderness
ANCILLARIES TVS TVS- trilaminar PE: uterus soft and

endometrium, boggy, Grape-like
B Hcg- >1,500: tissue, absent fetal
consider ectopic heart
2. B HCG
3. TVS
Complete:
snowstorm,
echogenic mass,
anechoic cystic
spaces, no fetal sac
Partial:
With fetal sac,
thickened placenta
MANAGEMENT Bed rest Unruptured: 1. Suction

1. Methotrexate curettage
2. No fetal heart 2. Hysterectomy
tone radical)
Rupture:
1. Salpingectom
y
DDx 1 DDx 2
PLACENTA PREVIA ABRUPTIO PLACENTA
CC: 2ND TRI
BLEEDING
DEFINITION
RISK FACTORS PRIOR CS! PRIOR ABRUPTIO Placenta

Prev. infection Hypertension
Smoker Multiparity
Multiparity PPROM
Uterine leiomyoma Smoker
>35 yo leiomyoma(submucosal)
Trauma
SIGNS/SYMPTOMS PainLESS bleed Painful uterine bleeding

Tachycardia Sudden abdom. Pain
Soft, nontender uterus Uterine tenderness/back pain
Sentinel bleed TETANIC uterine contractions
Baseline hypertonus
ANCILLARIES -TVS: for placental location TVS: for placental location

-Bleeding time/clotting time to
r/o DIC
MANAGEMENT >If W/ ACTIVE BLEED: Emergency CS

- Emergency CS! - For living viable fetus
>If PRETERM w/o Active - Vaginal delivery NOT
bleeding imminent
-Admit & observe for 3 days - Brisk hemorrhage
- give steroids(betameth) - Transverse lie
-give tocolytics(nifedipine)
- if after 2 days, no bleed, can
discharge-> advise pelvic rest
>If NEAR TERM, w/o active
bleed
- Sched ELECTIVE CS
DDx 1 DDx 2
PPROM
CC: WATERY VAGINAL
DISCHARGE
DEFINITION
RISK FACTORS
SIGNS/SYMPTOMS
ANCILLARIES
MANAGEMENT
DDx 1 DDx 2
PRETERM LABOR BRAXTON HICKS
CC: HYPOGASTRIC
PAIN
DEFINITION
RISK FACTORS
SIGNS/SYMPTOMS
ANCILLARIES
MANAGEMENT
DDx 1 DDx 2
CC: ELEVATED BP
DEFINITION
RISK FACTORS
SIGNS/SYMPTOMS
ANCILLARIES
MANAGEMENT
DDx 1 DDx 2
CC: RECURRENT
PREGNANCY LOSS
DEFINITION
RISK FACTORS
SIGNS/SYMPTOMS
ANCILLARIES
MANAGEMENT
NAME: MM AGE: 25 BIRTHDATE: DATE: August 23, 2021
ADDRESS: SEX: F CIVIL STATUS: # OF YEARS RELIGION: Catholic

Sampaloc, Manila live in (call center MARRIED:
agent)
OCCUPATION: Call center agent EDUCATION: COLLEGE NATIONALITY: Filipino
CC: Sumasakit ang tiyan (lower right portion) RLQ pain

● ONSET: 1 wk ago on off
○ Kaninang umaga matindi sakit
○ Pain started on same site
● LOCATION: Right Lower Quadrant
● DURATION:
● CHARACTERISTICS: “tumutusok” (sharp/stabbing pain)
● AGGRAVATING: None
● ASSOCIATED: (-) Dizziness (+) spotting - panty liner
● RELIEVING: Paracetamol (no relief) [No hot compress done]
● TEMPORAL: Intermittent/ on-and-off
● SEVERITY: 8/10 (5-6/10 1 week ago)
LMP:June 1st week

PMP: May 1st week
SYMPTOM 1: RLQ pain

I week onset on and off
This morning severe
Stabbing pain
No aggravating
With spotting, no dysuria, no dyschezia
Paracetamol twice, no relief
Progressing from 5-6/10 →8 /10
SYMPTOM 2:
●
SYMPTOM 3:
OBSTETRIC TOTAL PAST PREGNANCY: 0 FULL TERM: PREMATURE: ABORTION: ALIVE: OB SCORE:
HISTORY
G0
1. n/a
NOTES:
2.
NOTES:
3.
NOTES:

MENARCHE 14 y/o COITARCHE 18 yrs old
INTERVAL Regular (?) NO. OF SEXUAL 1 partner (live in)

PARTNERS Last contact: 2 wks ago
DURATION 3-4 days
POST-COITAL none
AMOUNT 3-4 regular pads/day, moderately soaked, no blood clots BLEEDING
SYMPTOMS No dysmenorrhea DYSPAREUNIA none
CONTRACEPTIVES Condoms
USE
LMP June 1st week
PMP May 1st week (not sure)
AOG 11-12 weeks (assuming LMP of June 1 or June 7)
EDC March 8, 2022 (assuming LMP of June 1)

SURGERIES, DM both
TRANSFUSION
HPN Mother
OB & GYN
PROCEDURES CANCER
Others:
Asthma - sibling
CVD- father
HOSPITALIZATION No hospitalization
Skin Cancer - grandfather
No Hepa B vaccine
Colonic CA - cousin and uncle
IMMUNIZATION
(Childhood, Hepa (+) COVID vaccine
B, Covid) No HPV vaccine
COMORBIDS
MEDICATIONS

1. HEADACHE
SMOKING 16 years old (5stick per day) If kasama barkada 10 sticks
2 years ago stopped, voluntary 2. BLURRING OF VISION
3. PROLONGED VOMITING
ALCOHOL Parties only (occasional) 4. FEVER
5. NONDEPENDENT EDEMA
COFFEE 6. EPIGASTRIC/RUQ PAIN
7. DECREASED FETAL MOVEMENT
DRUGS 8. DYSURIA
9. BLOODY VAGINAL DISCHARGE
DIET Fast food sa trabaho, cooked meals at home 10. WATERY VAGINAL DISCHARGE
EXERCISE Di kaya kasi night shift No pregnancy test done
REVIEW OF SYSTEMS:
GENERAL No change in appetite, Paggising masakit on-off pagtulog

Di nahihirapan umihi
SKIN, HAIR, NAILS Di nahihirapan dumumi
(-) Headache
EYE (-) Nausea and vomiting
(-) Fever
EAR (-) neck mass
(-) cough and colds
NOSE (-) shortness of breath
(-) abdominal pain??
(-) easy bruisability
MOUTH
(-) dyspnea
CARDIO
PULMO
GASTROINTESTINAL
GENITOURINARY
HEMATOLOGY
NEUROLOGIC
ENDOCRINE
MUSCULOSKELETAL

○ MENTAL STATUS: AMBULATORY, IN DISTRESS, conscious, ○ INSPECT THE VULVA (EXTERNAL GENITALIA)
coherent ■ (-) SCARS
○ BODY HABITUS: ■ (-) ERYTHEMA
○ WEIGHT: 130 lbs ■ (-) BLEEDING
○ HEIGHT: 5’0 ■ (-) DISCHARGE
○ BMI : 25.4 ■ (-) MASSES
● VITALS SIGN: ■ (-) RASH/ VESICLES/ ULCERATIONS
○ BP: 110/80 ■ PUBIC HAIR DISTRIBUTION - inverted triangle
○ HR: 85 ○ SPECULUM EXAM (INSPECT THE CERVIX)
○ RR: 20
■ (+) SMOOTH, VIOLACEOUS
○ TEMP: 37C
● ANTHROPOMETRIC DATA ■ DISCHARGE - slight bleeding coming out of external? os
○ HEIGHT: ■ (-) CERVICAL ECTROPION
○ WEIGHT: ■ (-) ULCERS
○ BMI: ■ (-) MASSES/POLYP
● (HEENT) EYES: ○ INTERNAL EXAM
○ PINK PALPEBRAL CONJUNCTIVA ■ CERVIX : (+) CERVICAL MOTION TENDERNESS, Length
■ UTERUS
○ No other deformities
○ No acne, discoloration ● Not Enlarged
○ No neck mass, neck is supple ● Slightly movable
○ No tracheal tenderness ● Anteverted
○ No oral discharge, No nasal discharge ● Mass
● CARDIO: ● Tenderness
○ ADYNAMIC PRECORDIUM, no HEAVES, LIFTS, THRILLS ■ ADNEXA
○ PMI left 5th ICS, MCL
● (+) R ADNEXAL TENDERNESS
○ Normal rate, normal rhythm
○ No murmurs ● Mass (+/-)
● RESPIRATORY: ■ No Bulging of CUL-DE-SAC
○ SYMMETRICAL EXPANSION, NO LAGGING, NO WHEEZES, ■ BISHOP’S SCORE
○ Clear breath sounds ● Dilatation:
○ No rhonchi ● Effacement:
● BREAST:
● Consistency:
○ INSPECTION:
● Position:
■ SYMMETRICAL
● Station:
■ (-) SWELLING
■ CLINICAL PELVIMETRY
■ (-) MASSES
● INLET: true, obstetric, diagonal conjugate (>11.5 cm)
■ SKIN CHANGES
■ (-) NIPPLE CHANGES eg. discharge (LNR: always specify) ● MIDPELVIS: ischial spine not prominent, curved
○PALPATION: sacrum, walls divergent
■ ASYMMETRY ● OUTLET: wide pubic arch, fist can fit the bituberous
■ SWELLING diameter (>8cm)
■ MASSES
■ EXAMINE AXILLARY LYMPH NODES: (-)
● SIZE ● RECTAL EXAM
● CONSISTENCY ○ INSPECTION
● FIXATION ■ No SKIN EXCORIATION
■ EXAMINE REGIONAL LYMPH NODES: (-) ■ No RASHES
● INFRACLAVICULAR ■ No HEMORRHOIDS
■ No ANAL FISSURE
● SUPRACLAVICULAR
■ No BLEEDING
● CERVICAL
■ No FISTULAE
● ABDOMINAL
■ No ABSCESSES
○ INSPECTION: slight globular, with striae, scars
○ PALPATION
■ FEMALE ESCUTCHEON ● RECTOVAGINAL EXAM
○ AUSCULTATION: NORMOACTIVE BOWEL SOUNDS ○ PALPATION
○ PALPATION: ■ No NODULARITY
■ Direct tenderness (RLQ) ■ No TENDERNESS
■ FUNDIC HEIGHT(18weeks), LEOPOLDS (28weeks) ■ No MASSES
■ (-) Psoas, obturator sign
■ masses?

● HEENT:
● GI:
● GU:
25 yo G1P0 No headache and dizziness
● MSK:
Sharp, intermittent RLQ pain 8/10 No dysuria, no trouble in defecation
● NEUROLOGIC:
Vaginal spotting No previous hospitalizations, no
Missed menses allergies, no weight changes, no blurring
LNR COMMENTS:
of vision, no nausea and vomiting, no
- When doing PE, ask about the findings you want to find out; be
Previous smoking history fever, no neck mass, no cough and
systematic
Obese (BMI of 25.4, asia pacific) colds, no dyspnea, no easy fatigability,
- Tell pt to void prior to Pelvic exam
no bruising, normal HEENT, pulmonary,
- Ask for palpable mass in adnexa
PE CV, breast exam,
- Both clerks should be able to discuss in the Assessment/Plan portion
Abdomen slightly globular with striae
- Give ddx for ectopic ruptures and ectopic unruptured
RLQ tenderness
Violaceous cervix (Chadwick) - probable
R adnexal tenderness
TENTATIVE DIAGNOSIS/ FINAL DIAGNOSIS: G1P0 to consider ectopic pregnancy, 11-12 weeks AOG by LMP, probably ruptured ; Obese Class I

This is a case of a 25 yo patient who came in with a chief complaint of sudden onset of sharp, stabbing RLQ pain gr. 8/10, not relieved by medications. This was
accompanied by vaginal spotting. Patient’s last menstrual period was 11 weeks ago (June 1st week), pregnancy test was not yet taken but on PE, chadwick’s
sign was noted. Other PE findings include R adnexal tenderness and cervical motion tenderness
Patient in distress
If ruptured: (wala pa sa patient)

-Hypotensive, tachy
-Severe hypogastric pain
-bulging cul-de sac
-neck/shoulder pain
● Basis of ruptured EP present in patient: (+) severe RLQ pain, direct and rebound tenderness in RLQ, cervical motion tenderness
1. Ectopic Pregnancy, Ruptured Triad: Abdominal pain, Absence menses,

Irregular/minimal vaginal bleeding (spotting)
Sharp intermittent RLQ pain (from 5-6/10 pain to 8/10)
Vaginal Spotting
Missed menses
RLQ tenderness
Chadwick’s sign
Cervical motion tenderness
R Adnexal tenderness
2x4 cm mass in R adnexa
RF:
Smoking
2. Corpus Luteum Cyst, Ruptured Halban’s Triad Rule out via HCG serum assay (di pa nagawa)
Unilateral Pelvic Pain ● (Can consider but can’t be ruled out yet)
Delay in Normal Menses followed by Spotting
Tender adnexal mass
3. Ovarian Torsion RLQ Pain Acute severe unilateral pain

Vaginal bleeding (spotting) No mass
(-) vomiting, nausea
(-) mass
4. Appendicitis RLQ Pain (-)Pain starting from the epigastric radiating to the RLQ
(-) fever, (-) nausea, vomiting
Negative Psoas, Obturator signs
Chadwick’s sign (probable sign of pregnancy)
5. Threatened Abortion (for unruptured ddx) RLQ Pain No waxing/waning contractions

Vaginal bleeding (spotting) Cervix closed
Pain is localized at the right side (hypogastric dapat)
Parang di rin ata marrule out? Yes
PID (unruptured ddx) Cervical motion tenderness No fever

Lower abdominal pain Normal VS
Pain No foul discharge
Adnexal tenderness Usually bilateral pain (systemic infection thus both
tubes affected)
Onset of pain is after menses
Walang peritonitis signs?
No rebound tenderness
No decreased bowel sounds

1. Transvaginal Ultrasound PNCU:
a. Ratio: To check for the ff:
i. Endometrial Findings: Thickened endometrium (usually Transvaginal Ultrasound: confirm pregnancy, AOG, location and number of fetus
trilaminar in ectopic) CBC: Determine hematologic status, and assess the physiologic anemia of pregnancy
ii. Adnexal Findings: inhomogenous complex adnexal mass (due to hemodilution from increased intravascular volume)
separate from ovary ● Right
iii. Cul de Sac Findings: anechoic or hypoechoic fluid in cul ● Elongated 4x3 cm
de sac ● (+) min fluid in cul de sac
2. CBC ● leaking
a. Ratio: If ruptured, Hgb and Hct do not usually reflect ● (-) IUP
hemodynamic status after several hrs later ● Thickened endometrium
BT with Crossmatching: ABO incompatibility, for possible blood transfusion kasi
3. Laparoscopy (if needed) - diagnostic and therapeutic maguundergo surgery
a. Ratio: Direct visualization B-hCG (If TVS results are inconclusive) -
4. Blood typing ● Discriminatory Zone: 1500 mIU/mL
5. AST, ALT (before giving methotrexate) ● Above discriminatory level PLUS failure to visualize an intrauterine pregnancy
6. BUN crea (before giving methotrexate) on ultrasound = ECTOPIC
7. bHCG (serial) - confirm ectopic pregnancy ● Wait for TVS before requesting this
Urinalysis: Rule out infection
Surgical Management:
Salpingotomy/Salpingostomy
● ruptured ectopic pregnancy
● For size <2cm, distal ⅓ of fallopian tube
● Removes product of conception - immoral if live ectopic
Salpingectomy :
● Primarily for ruptured ectopic pregnancy - UTZ leaking
● Entire length of affected tube is removed
● Complete excision to minimize recurrence in the tubal stump
● 4x3 cm - indication
● If alive - ectomy pa din (principle of double effect) - no direct attack on the
fetus
Salpingostomy
§ When ectopic mass size <2 cm
§ Location: distal third of the fallopian tube
§ Typically used to remove a small unruptured pregnancy.
§ Linear incision made on the antimesenteric border,
contents evacuated, and incision is left unsutured to heal
by secondary intention (portion of tube is preserved!)
§ Preserving the portion of the tube if the size is >2 cm will
only predispose the woman to future ectopic
pregnancies!
Salpingotomy
§ Same as salpingostomy except the incision is closed by
delayed-absorbable suture. BOTH NOT ETHICAL
Prescription (IF MEDICAL MANAGEMENT)

● Methotrexate
○ For unruptured ectopic pregnancy, <3.5cm, initial BHCG <1000,
absent fetal cardiac activity
○ (-) FHT
Follow up
After lab results are

cc/hr
LABS MEDICATIONS Medications should include name, dose, route
CALL HO
LABS LABS
Ex. if HR <60 bpm

GOOD LUCK AND GOD BLESS <3
Topic Ectopic Pregnancy / Pregnancy of Unknown Location
Facilitator RMG
Clerks Heredia J, Hernandez
Date Aug 23, 2021
HISTORY

ko na po.
General Data Name: Maryln Dee

Age > 35 (risk factor for Previa, Age: 42
Abruptio) Birthdate: Nov 1
Birthplace: Tondo
Address: QC
Nationality: Filipino
Religion: Catholic”
Occupation: accountant
Civil status: married
● Chief Complaint: Ano po

ang rason kung bakit po CC: hypogastric pain
kayo nagpa-konsulta
ngayong araw?
● If answer is related to
pregnancy: ask if alam
niyang buntis siya and if
nag pregnancy test na
● First time ninyo po ba
magpa-konsulta? Kung
hindi first time, tanungin
kung anong diagnostic
at lab na pinagawa and
result?
History of Present
Illness:
O: Kailan po ninyo unang Onset: 2 days ago pero konti lang
napansin? Location: right side sa ilalim ng pusod
D: Gaano katagal kapag Duration: 2 days
dinudugo kayo? Tuloy-tuloy po Character: may masakit , tuloy tuloy
ba ang pagdudugo? Aggravating: tuloy tuloy
C: Masakit po ba? Anong Alleviating: Mefenamic
klaseng sakit Marami po ba?
- Abruptio (painful) Relieving: Mefenamic acid 500 mg 3x a day ,
A: May ginawa po ba kayo Temporality:
anung napansin ninyo yung Severity: 4-5/10 , after meds, 2/10
pagdudugo niyo?
A: May iba pa po ba kayo Ask for Danger signs of pregnancy
Dysmenorrhea? Pagkahilo? N Meron po bang pagsakit ng ulo
Pamumutla? N Panlalabo ng mata
R: May ginagawa po ba kayo N Hindi nawawalang pagsusuka
dito para mawala? N Lagnat at panginginig ng katawan
S: If masakit, gaano kasakit? N Pamamanas ng kamay at paa
Pwede niyo po bang i-rate from Y/N Sakit sa tiyan
1-10, 10 po ang pinakamasakit Y/N Napansin po bang pagbabago sa paggalaw po ni baby? Nabawasan
po ba? (ONLY IF WITH QUICKENING!!!)
May mga gamot po ba kayong ● Nulli: 18-20 weeks
iniinom ngayon? Mga iron? Folic ● Multi: 16-18 weeks
acid? Calcium? Multivitamins? N Sakit sa pag-ihi o hirap sa pag-ihi
Y Meron po bang matubig o madugong lumalabas sa pwerta
- Spotting - kanina lang
Gano karami ung spotting
● Blurring of vision, headache, convulsions, edema of hands and
feet (preeclampsia)
Pregnancy test -
Pag sure na pregnant: bago pa po tayo tumuloy, tanong ko lang po

ung unang araw ng huling regla ninyo para lang po malaman kung
gaano na po katagal ang possible na pagbubuntis ninyo.
LMP - july 5
PMP -
Focused ROS: General Survey: may pagbabago po ba sa timbang, pagbago sa pag
Only ask pertinent to CC and kain o nakakaranas po ba ng pagkahina?
focus on those related to () Weight Changes
danger signs () Changes in appetite
() Fever
() Malaise
() Sleep Changes
Breast: (will already do in PE)

() Masses
() Discharge
() Tenderness
() Nipple Changes
Skin:
() Change in color
() Itchiness
HEENT:
Pulmonary:
() Cough
() Wheezing
Cardiovascular:
() Chest Pain
() Palpitations
() Leg swelling
Gastrointestinal:
() Nausea
() Vomiting
() Abdominal Pain
() Dysphagia
Genitourinary:
(-) Dysuria

() Joint swelling
() Weakness
() Headache
() Syncope
() Memory loss
() Polydipsia
() Polyphagia
() Polyuria
magalit)

● None
asthma, TB, sakit sa thyroid, PCOS, ● Nung nanganak
ninyo kasama po ng pagkakaroon ● none
o kaya pagdami po ng mga ● None
ultrasound para po sa obaryo
● none
ninyo?)
Immunizations:
○ Gout: masakit po ba ang
● Covid - sinovac
kasukasuan?
● May
● Past hospitalizations/surgeries: ● June
Naospital o naoperahan na po ba dati?
○ Always ask year, reason for Current Medications/Supplements:
operation, any complication? ● Generic Name:
● Injuries/ Accidents: May mga aksidente ● Brand:
po ba dati na nainjure kayo? ● Dose:
● Blood transfusion: Nasalinan na po ba ● OD/BID:
ng dugo? Multivitamins
● Immunizations: Nabakunahan na po ba - eversince
laban sa cervical cancer o HPV vaccine? Allergies:
Nagkaroon na po ba ng flu vaccine? ● Saging and lansones
ngayon? Para saan po ito? Generic Prenatal checkup:
doctor prescribed? [If HTN or DM, ask if - First pncu
-
wala?
or labs
resulta?
po bang bukol?
Family History: Father: htn, dm

May history po ba ng sakit sa pamilya Mother:
tulad po ng DM, HTN, CA (breast, Siblings:
cervical, endometrial, ovarial), asthma, Other family members:
mga sakit sa puso, pcos, o ibang mga
genetic na sakit po?
Diet: kahit ano
Activity Level/Exercise: tennis before then stopped
Personal and Social History: Smoking: no
Alcohol Intake: pre pregnancy
- Depende
- Stopped now
Illicit drug use:
- None
OB-GYNE History
Menstrual History: If hindi na-ask before:

LMP - July 5
PMP -
M - Ilang taon po kayo nung una kayong niregla?

I - regular Regular po ba kayo nireregla? Kunyari ho April 5
niregla kayo, kailan po ninyo ineexpect ang susunod nyong regla?
○ If irregular: mga gaano po katagal na hindi kayo
nireregla? Mga ilang buwan po kayong hindi
dinadatnan?
D - Ilang araw po ito nagtatagal? 3 days
A - Ilang pads po ang nagagamit nyo kada araw ng regla? Ano po
ang gamit nyo regular pads o night pads? 3 pads moderately
soaked Napupuno po ba to?
3 days, tama lang
S - May nararamdaman po ba kayong sintomas tuwing
nagreregla? Tulad ng Sakit sa puson, pagkahilo, pagsusuka?
None

● Nabuntis na po ba kayo dati?
● GP (TPAL) nasabi nyo po kanina may Gravidity:
anak po kayo
Parity:
● G: tanong ko lang po kung Ilan po ang
G1 (2008):
lahat ng pagbubuntis ninyo, at kung sakali
● BB /girl?
po ilan po dito ang nakunan?
● Iisa lang ba ang ama sa lahat? ● AOG husto
○ Yung unang anak niyo po, kailan ● BW03.2 kg
po pinanganak? ● NSD
○ Babae o lalaki? ● Where:
○ Naka-ilang buwan po siya nung ● Complications: none
pinanganak? Husto po ba? G2 (2011)
○ Naalala niyo po ba yung timbang ● BB boy
at haba po ni baby ● AOG husto
pagkapanganak? ● BW 3.1 kg
○ Normal po ba ang panganganak o ● Normal delivery
cesarean po?
● Where:
● Complications: none
midwife?
- 1st:
- 2nd:
- 3rd:
How frequent is the Prenatal Check-up?
Laboratories done:
● CBC
● Urinalysis
● FBS OGTT
Medications:
Obimin (multivitamin for pregnant)
Sangobion (iron supplement)
Part of the ‘History of Present Pregnancy’ if no
complaint. This will be the last part of HPP.
A separate entry if (+) complaint
Always ask for the ff information every PNCU (PreNatal Check

Up): Signs & symptoms experienced by the patient
Iron supplement
Calcium
Immunizations:
Tetanus Toxoid
Hepatitis B
Influenza
Pneumococcal
CBC, platelet count
Blood typing
HBsAg
VDRL / RPR
HIV Testing
History of discharge?
Vulvar itchiness?
Ulcerations?
Warts?
Pap smear with dates and results (last year, normal findings)?
Sexual History Coitarche:

- Only ask if No. sexual partner/s:
needed talaga Occupation of Partner/s:
since ayaw to Regularity: (Gaano po kadalas)
tinatanong ni Associated symptoms: none (dyspareunia, bleeding)
doc mongon Date of last sexual contact:
- To know risk
for cervical
cancer (sex at Type of contraceptive used:
around teens Generic/brand name:
and no HPV Duration of use:
vaccine) Reason for choice
• Important to ask the Satisfaction with method:
o ex. call center agent: high
risk for STD Undesirable side effect:
• Elicit promiscuity of patient If already stopped, Date?
(risk factor for STDs like HIV)
PHYSICAL EXAM

- Conscious, coherent, ambulatory, not in cardio respi distress,
oriented to 3 spheres
Vital Signs BP: 110/80

● Pre-pregnancy: none
○ w/ meds
○ w/o meds
● Current: 110/80
HR: 80
RR: 18
Temp: 36.1
Anthropometric Data Height: 5’2’’

Weight (Prepreg):
Weight (Current): 120
BMI (Prepreg):
BMI (Current):
Skin Are there any lesions? None
Warm to touch,
appropriate skin turgor, ()
pallor, () jaundice, ()
cyanosis, () active
dermatoses, ()
ecchymoses

Epulits
EYES: Head:
Walang naman Eyes:
problema sa paningin? ● Pink palpebral conjunctiva
Walang panlalabo ng
Ears:
paningin? Nose:
pagkaduling? Mouth:
MOUTH: ● Is there any bleeding in the
Pagdudugo sa gilagid? gums? No
Pagkawala ng ● Loss of taste?
panlasa? Neck: Unremarkable
● Are there any masses? No
NECK:
● Thyroid midline and
May napansin po ba moves with deglutition,
kayong bukol sa may Thyroid not enlarged, (-)
leeg? bruit
● No palpable cervical
lymphadenopathy
● JVP
Lungs INSPECTION Symmetrical chest expansion

PALPATION Tactile fremitus
PERCUSSION Dull, resonant, hyperresonant
AUSCULTATION Clear breath sounds

● No murmurs
Breast Inspection
If pertinent? Any gross abnormality on the breast - none
Normal
• Wash hands
• Confirm patient details Asymmetry
• Explain Examination Before assuming asymmetry, always ask if it is always have been asymmetrical
• Gain Consent The dominant side usually appear larger than the other side
present o Male gynecologist Swelling
a
Masses
female assistant Skin Changes
• Expose patient
Nipple Changes
o Thank Patient Pressing into hips
o Wash Hands (Contraction of Pectoralis Major)
recommended once a month Hands behind head
after o Push elbows back and lean forward (will exacerbate skin dimpling)
menstruation
▪ Hormone has less effect in
the breast
Asses:
physician) breast exam once Swelling?
a year
Mass?
pap smear Location
diagnostic o If biopsy is needed, Size/Borders
breast CA = request
Fixation
• Non-palpable lesions can be Examine Axillary Lymph Nodes
detected in mammography
Size
Consistency
Fixation
Examine Regional Lymph Nodes
Infraclavicular
Supraclavicular
Cervical
Abdominal I: Shape, striae (color), scars (location, length, hypertrophic vs keloid)

- Globular or flat? ***also depend this on AOG kasi globular tlga pag buntis
- Flabby
- No scars and striae
A: character and frequency of bowel sounds normoactive
- FHT:
Pe: DON’T PERCUSS IN PREGNANT
Pa: Mass palpated, tenderness, no rigidity, no guarding, soft, non-tender
- Flabby, soft, with positive tenderness on the right LQ )(-) rebound

tenderness
- No mass palpated
- Bulging posterior fornix - none
- Cervical motion tenderness
Palpation: FH= cm EFW= _____kg
Leopold's Maneuver
LM1 (Fundal Grip)


LM4 (Pelvic Grip)

Engaged or not?
Peritonitis (board like rigidity)

() Tenderness
Auscultation: FHT= ______ bpm located on the ______________, note for

regularity.
Genitourinary CVA Tenderness
Extremities ● Presence of edema?

Inask na sa danger sign ● Pulses full and equal = 2+?
● Deformities?
● varicosities
Pelvic ASK MUNA TO VOID
IE - don’t do if External Genitalia; Inspect the Vulva - none

second half of ● Lesions
pregnancy!! ● Scars
Ask to empty bladder ● Erythema
● Bleeding
Introduce yourself
● Discharge
o Patient’s name and date of ● Masses
pregnancy Check patient’s ● Rash/Vesicles/Ulcerations
● *Pubic Hair Distribution
o Explain that light vaginal - inverted triangle - yes wax
- right mediolateral episiotomy scar
o For male physicians, always - parous opening
to accompany you
Gain consent
mass, prolapse and

used o Gloves
o Speculum
o Lubricant
o Sample Pot
used)
Speculum Exam
● Cervix:
● Speculum Exam - Normal: Violaceous, with minimal bleeding from os
- Hold the handle ● Vagina: no lesions
of the speculum ● Cervix:
with your ○ Dilatation:
dominant hand, ○ Effacement
and ○ Position
● open the labia ○ Consistency
minora with the ○ Presentation
other one (use ○ Station
thumb and 5th
finger). Insert the ● Inspect the Cervix:
CLOSED ○ Color: is it violaceous?
speculum gently, ○ Ulcers:
sideways at first, ○ Masses/ Polyp:
then slowly rotate ○ Discharge (amount, color, description) -
to the normal ○ Shape of external os:
position, then - parous cervical os (fish mouth) or
gently open the - nulliparous cervical os (circular)
speculum. Inspect
the cervix.
INTERNAL CERVIX:
EXAMINATION (IE) ● Short, soft, closed
Don’t do if the vaginal ● (-) Cervical motion tenderness
bleeding is on the
second half of UTERUS:
pregnancy ● Uterus normal sized (if enlarged, ask for how many months size?), anteverted,
movable, tender, consistency
Bimanual Exam of the isthmic portion Ovaries adnexa cannot be assessed
ADNEXAL:
● No adnexal masses with tenderness
Rectal Exam ONLY IF INDICATED
Inspection
virgin or has no sexual history. • Rashes
Do not do
vaginal exam given those • Hemorrhoids
indications
• Anal Fissure
• Confirm patient details • Bleeding
• Fistulae
quick examination • Abscesses
opt to stop the procedure if
there is any discomfort
• Gain Consent
Palpation
• Ensure a chaperone is ● Lubricate the finger
present (especially if Male ○ Use the Index Finger
Gynecologist) ● Insert the finger gently into the anal canal
○ Gloves
○ Lubricant
○ Paper Towels
○ Cervix
○ Adnexal area
• Inspection
• Palpation
and assess
○ Blood
○ Stool
○ Mucus
patient
• Wash Hands
assessment
Nodularity
vagina
nodularity,
mass.
● Example:
examine
the Middle
● Generally:
pelvic organ
prolapse.
enough with IE)
sac area
toward the back
INPUT HERE PLS

SALIENT FEATURES
42 years old G3P2 (2002), 7 weeks AOG by LMP BMI 21.9 (normal)
Continuous right hypogastric pain (2 days ago) Abdominal:
● Partially relieved by intake of Mefenamic acid (500 ● Flabby, soft
mg/tab, PRN) → 2/10
● (+) tenderness on RLQ
● 4-5/10 to 2/10 upon intake of medication
Vaginal Spotting (few hours PTC) ● (-) rebound tenderness
LMP: July 5, 2021
PMP:
(+) pregnancy test Pelvic:
● Minimal bleeding from cervical os
● Cervix: soft long closed, (-) cervical
● Uterus: Normal size
● Adnexa: No mass, with tenderness (RLQ)
● No bulging of the posterior fornix
AOG Computation: EDD Computation:
26 + 23 = 49/7 EDC: April 12, 2022
= 7WKS AOG July 5
7-3 = 4 April
5+7 = 12
+ 1 yr
G3P2 (2002) Pregnancy of unknown location 7 weeks AOG by LMP, r/o Appendicitis and UTI
Signs and Classic Triad of Ectopic Pregnancy:

Symptoms ● Missed menses
● Hypogastric pain
● Vaginal spotting
Physical Abdominal:
examination (+) Tenderness RLQ
(-) rebound tenderness
Pelvic:
● Minimal bleeding from cervical os
● Adnexa: No mass, with tenderness (RLQ)
● No cervical motion tenderness
Diagnostic/ Teka if Ectopic diba more on UTZ, then yung B-hcg nalang mag prenatal pa ba siya?
ancillary (make
sure to request for CBC - baseline, to check if there are any infection, IDA
labs that will be
cost-effective)
Leukocytosis
Urinalysis:
2 days ago - dapat pumutok na if appendicitis

Highest risk of ectopic pregnancy - tubal pregnancy
TVS
- Endometrial findings
- Thickened endometrium usually trilaminar
- Decidual cyst
- Pseudogestational sac
- Adnexal findings:
- Visualization of an inhomogeneous complex adnexal mass - ring of fire- placental blood flow at
the periphery
- Cul de sac: anechoic or hypoechoic fluid -> hemoperitoneum
Thickened endometrium
PUL
No adnexal mass
B-Hcg - to get the baseline and establish if ectopic pregnancy

- >1500: ectopic pregnancy
- <1500: x2; intrauterine
- <1500 dec failing uterine pregnancy
Laparoscopy?
First prenatal check up:

Urinalysis: screening for asymptomatic bacteriuria (need pa ba to)
Transvaginal Sonography: to confirm pregnancy, viability and location; and obtain sonographic age of
gestation
- Ring of fire
crown rump length (CRL) since <12 weeks AOG
● (Example of a report: TVS showed a single live intrauterine pregnancy, 12-13 weeks AOG by CRL, with
good cardiac activity.)
● Fetal heart tone: heard at 5 weeks
- Yolk sac: 5 weeks
- Fetal heart beat: 6-8 weeks
- Establish fetal number, location,
For AOG:
- Fetal biometry - >13 wks (14-26 weeks) (biparietal diameter, femur length, abdominal circumference,
head circumference)
- BPS
- Fetal tone
- 10x every 2 hours
- Fetal breathing
- Reactive fhr: 2 or more episodes of acceleration of >15 bmp and of >15s associated
with FM within 20 mins
- Contraction
* If need surgery, don't forget to request for cbc, blood chem, pt/ptt etc. and COVID-19 rt-pcr swab test!
Management Goals:
Management:
Admit patient
Monitor VS and pain
● If lumala ang pain, warrants immediate operation
Monitor b-hcg
Laparotomy:
- If ruptured:
- Salpingectomy: resection or removal of entire length of the affected tube to minimize
recurrence of ectopic pregnancy
- Criteria: ruptured, or live ectopic even if unruptured
- Principle of double effect, no direct attack on fetus
- If unruptured:
- Criteria: unruptured, distal third of fallopian tube, <2 cm size
- Salpingostomy: incision is left unsutured and heal by secondary intention
- Salpingotomy: incision is closed by suturing
- First pregnancy, to conserve, young
Appendicitis:
- Appendectomy
Theoretical if medical approach:

Methotrexate 1mg/kg IM
- Candidates: initial B-hcg is <1000mIU/mL
- Ectopic mass <3.5cm
- Absent fetal cardiac activity
- Unruptured ectopic pregnancy
Monitor b-HCG days 1, 4, 7
Goal: b-hCG <15mIU/mL
Patient must be asymptomatic, compliant and fetus must not be alive
Preventive:
Based on Chief Complaint:
Differentials Ectopic Pregnancy Appendicitis Ovarian Torsion Threatened Abortion
Signs and Symptoms Missed menses RLQ pain (periumbilical Acute severe unilateral Vaginal Bleeding with
> migrates to rlq) lower abdominal pain crampy hypogastric pain
Abdominal Pain (sharp,
Anorexia Nausea and vomiting
stabbing, or tearing) Nausea and vomiting AUB
Minimal vaginal
bleeding or spotting
Physical examination PATIENT: Low-grade fever Closed Cervix

● RLQ (mcburney’s point) Uterine Size compatible
tenderness with AOG
THEORETICAL: (+) guarding
Unruptured Right adnexal
● Uterus slightly tenderness
enlarged due to
hormonal Rovsing’s sign (rlq pain
stimulation on palpation of llq)
● (+) adnexal
mass Obturator sign (rlq pain
● Tenderness on on flexion of right hip
palpation upon and knee)
palpation
● Cervical motion Psoas sign (rlq pain on
tenderness right hip extension)
Ruptured
● Severe
abdominal pain
● Generalized
tenderness
● Cervical motion
tenderness
● Bulging
posterior fornix
(hemoperitoneu
m)
● Tender boggy
mass beside
the uterus
● Diaphragmatic
irritation
● Signs of
peritoneal
irritation
● Signs of
hemodynamic
instability
Reason for R/o? No rebound tenderness
If pain lasts >24 hrs->

will rupture; in the px
pain is already 2-3 days
Diagnostic/ ancillary a. CBC - For ruptured

ectopic pregnancy,
Hgb and Hct levels
don’t usually
reflect the
hemodynamic
status of the
patient until
several hours later
b. Transvaginal
ultrasound
c. B-hCG (If TVS
results are
inconclusive)
d. Laparoscopy
(diagnostic and
therapeutic)
Management Salpingectomy - best

management
considering her age
Salpingostomy - not
recommended for her
age; will increase risk
for ectopic pregnancy
again


DISCUSSION
Salient features
Clinical Impression
Ddx
First loop notes (Sept):
First loop notes

(July Group)
Work - Up
Final Diagnosis
Management
Prevention
NOTES FOR CARES

NAME: Maria reyes (“Mary”) AGE: 23 BIRTHDATE: 1998 DATE: August 23, 2021
ADDRESS: QC SEX: F CIVIL STATUS: # OF YEARS RELIGION: Catholic

Married MARRIED: 1
OCCUPATION: WFH- Secretary EDUCATION: College Accountancy NATIONALITY: Filipino
CC: Missed menses

● ONSET:
● LOCATION:
● DURATION: 2 months of missed menses
● AGGRAVATING
● ASSOCIATED: Nausea and Vomiting usually in the morning, sensitive smell, Breast tenderness, Darker areola and nipples
● RELIEVING
● TEMPORAL
● SEVERITY
LMP:June 12- 15, 2021

PMP: May 14-16
SYMPTOM 1: Nausea and vomiting, Morning sickness(?)

● Every morning
SYMPTOM 2: Breast tenderness

● Especially morning
● Darker areola and nipples
SYMPTOM 3:
First consult, (+) pregnancy test (2 weeks ago)
OBSTETRIC TOTAL PAST PREGNANCY: FULL TERM: PREMATURE: ABORTION: ALIVE: OB SCORE:
HISTORY
G1P0
1. 2021 Current Pregnancy
NOTES:
2.
NOTES:
3.
NOTES:

MENARCHE 13 y/o COITARCHE 22 y/o
INTERVAL 28-30 days NO. OF SEXUAL 1

PARTNERS
DURATION 3-4 days
POST-COITAL None
AMOUNT 2-3 pads (regular), first 2 days fully soaked, no blood clots BLEEDING
SYMPTOMS Dysmenorrhea on 1st day, Breast tenderness 2 weeks before? DYSPAREUNIA None
CONTRACEPTIVES None
USE
LMP June 12- 15, 2021
PMP May 14-16
AOG 10-11weeks
EDC March 19, 2022

SURGERIES, None DM None
TRANSFUSION
HPN None
OB & GYN
PROCEDURES CANCER None
Others:
HOSPITALIZATION No No asthma
No thyroid disease
IMMUNIZATION Complete childhood vaccinations (mother said)
Hepatitis B (2020)
COVID19 vaccine (May 2021)
COMORBIDS None
MEDICATIONS None

1. INTRACTABLE HEADACHE >20wks
SMOKING No
2. BLURRING OF VISION >20wks
ALCOHOL No 3. PROLONGED VOMITING
4. FEVER
COFFEE 5. NONDEPENDENT EDEMA FACE AND HANDS >20wks
DRUGS No 7. DECREASED FETAL MOVEMENT - M: 16-18; P: 18-20 wks
8. DYSURIA
DIET Chicken, fish, vegetables 9. BLOODY VAGINAL DISCHARGE : abortion
10. WATERY VAGINAL DISCHARGE : PROM, abortion
EXERCISE Regular
REVIEW OF SYSTEMS:
GENERAL No headache,
No blurring of vision
SKIN, HAIR, NAILS No edema
No abdominal pain
EYE No vaginal discharge
No dysuria
EAR
NOSE
MOUTH
CARDIO
PULMO
GASTROINTESTINAL
GENITOURINARY
HEMATOLOGY
NEUROLOGIC
ENDOCRINE
MUSCULOSKELETAL

○ MENTAL STATUS: AMBULATORY, NOT IN DISTRESS, conscious, ○ INSPECT THE VULVA (EXTERNAL GENITALIA)
coherent ■ SCARS - no gross lesions
○ BODY HABITUS: ■ ERYTHEMA - no erythematous areas
○ WEIGHT: 111 lbs ■ BLEEDING
○ HEIGHT: 5’5” ■ DISCHARGE - no discharge
● VITALS SIGN: ■ MASSES
○ BP:110/70 ■ RASH/ VESICLES/ ULCERATIONS
○ HR: 80 bpm ■ PUBIC HAIR DISTRIBUTION - inverted triangle distribution
○ RR: 18rpm
○ SPECULUM EXAM (INSPECT THE CERVIX)
○ TEMP: 36.5C
● ANTHROPOMETRIC DATA ■ SMOOTH, VIOLACEOUS - bluish/violaceous in color
○ HEIGHT: 5’5 ■ DISCHARGE - minimal mucoid discharge
○ WEIGHT: pre-preg 110lbs, preg 5’55’’ ■ CERVICAL ECTROPION
○ BMI: 18.5, Normal ■ ULCERS
● (HEENT) EYES: ■ MASSES/POLYP
○ PINK PALPEBRAL CONJUNCTIVA ○ INTERNAL EXAM
■ CERVIX - soft (Goodell’s), long, closed
○ No other deformities
○ No acne, discoloration ■ UTERUS - slightly enlarged, movable, non-tender
○ No neck mass, neck is supple ■ ADNEXA - No palpable masses, non-tender
○ No tracheal tenderness ■ CUL-DE-SAC - deep fornices
○ No oral discharge, No nasal discharge ■ BISHOP’S SCORE
● CARDIO: ● Dilatation:
○ ADYNAMIC PRECORDIUM, no HEAVES, LIFTS, THRILLS ● Effacement:
○ PMI left 5th ICS, MCL
● Consistency:
○ Normal rate, normal rhythm
○ No murmurs ● Position:
● RESPIRATORY: ● Station:
○ SYMMETRICAL EXPANSION, NO LAGGING, NO WHEEZES, ■ CLINICAL PELVIMETRY
○ Clear breath sounds ● INLET: true, obstetric, diagonal conjugate (>11.5
○ No rhonchi cm)
● BREAST:
● MIDPELVIS: ischial spine not prominent, curved
○ INSPECTION:
● sacrum, walls divergent
■ ASYMMETRY - symmetrical
● OUTLET: wide pubic arch, fist can fit the
■ SWELLING
bituberous diameter (>8cm)
■ MASSES - no gross lesions
■ SKIN CHANGES - hyperpigmentation in the areola and
nipples
● RECTAL EXAM
■ NIPPLE CHANGES - not everted ○ INSPECTION
○ PALPATION: ■ SKIN EXCORIATION
■ ASYMMETRY ■ RASHES
■ SWELLING ■ HEMORRHOIDS
■ MASSES - no palpable mass ■ ANAL FISSURE
■ EXAMINE AXILLARY LYMPH NODES - not palpable ■ BLEEDING
● SIZE ■ FISTULAE
■ ABSCESSES
● CONSISTENCY ○ PALPATION
● FIXATION ● RECTOVAGINAL EXAM
■ EXAMINE REGIONAL LYMPH NODES ○ PALPATION
● INFRACLAVICULAR ■ NODULARITY
● SUPRACLAVICULAR ■ TENDERNESS
● CERVICAL ■ MASSES
● ABDOMINAL
○ INSPECTION: Flat and soft, no striae
■ globular, moderate striae, scars
■ FEMALE ESCUTCHEON
○ AUSCULTATION: Normoactive
■ NORMOACTIVE BOWEL SOUNDS
○ PALPATION: No palpable mass, No direct or rebound tenderness
■ No Direct and rebound tenderness
■ FUNDIC HEIGHT(18weeks), LEOPOLDS (28weeks)

● HEENT:
● GI:
● GU:
23 yo G1P0 No fatigue
● MSK:
Missed menses - presumptive No striae gravidarum
● NEUROLOGIC:
Morning sickness - presumptive No headache
Breast tenderness - presumptive No blurring of vision
Nausea - presumptive No edema, no abdominal pain
Hyperpigmented areola - presumptive No vaginal discharge
(+) pregnancy test - probable sign No dysuria
Chadwick’s sign (Bluish cervix and No previous hospitalizations/surgeries,
vagina) -presumptive no other comorbidities
Goodell’s (Softening of cervix)
-probable
Uterus slightly enlarged- probable
TENTATIVE DIAGNOSIS/ FINAL DIAGNOSIS: G1P0, t/c EARLY PREGNANCY, 10-11 weeks AOG by LMP
Computation of AOG:
● June -30 days-12
● July 31 days
● Aug 23 days = 72 days / 7 -> 10 2/7
Patient is a 23yo who came in with a chief complaint of missed menses for 2 months accompanied by nausea, and breast tenderness with a positive Pregnancy test. This is
her first prenatal consult.
Presumptive signs:
- Missed menses
- Morning sickness, nausea
- Breast tenderness
- Hyperpigmentation of the areola
- (+) chadwick’s sign- bluish cervix and vagina
Probable signs
- (+) pregnancy test
- (+) goodell’s sign- softening of the cervix
- Uterus slightly enlarged
1. Pregnancy Missed menses No fatigue

Morning sickness No striae gravidarum
Breast tenderness
Hyperpigment areola and nipples
(+) pregnancy test
Violaceous cervix (chadwick)
Goodell’s sign
2. PCOS Missed menses Normal BMI

No acne
Inverted triangle hair distribution
Hyperandrogenism - hirsutism
3. OCP use Missed menses No history of use of contraceptives

4. Hyperthyroid - Prolonged use

● TRANSVAGINAL ULTRASOUND PNCU:
● FBS Request:
● LIPID PROFILE ● CBC, blood typing (ABO with Rh) - baseline hct hgb ABO AND RH
● URINALYSIS INCOMPATIBILITY, baseline for future Blood transfusion
● CBC+PLT Determine hematologic status, and assess the physiologic anemia of pregnancy
● ABO CROSSMATCH BT (due to hemodilution from increased intravascular volume)
● SEROLOGY - Possible transfusion in the future
● PAP SMEAR Also check for leukocytosis for possible ongoing infection
● KOH - Neutrophils elevated
● COAGULATION STUDIES - Expected: Elevated WBC
● THYROID FUNCTION TEST - Correlate clinically -- no fever
● JZM Comments ○ IDA
● Be systematic about asking questions from head to toe ○ hemoglboin
● Missed out on pulses and extremities ○ Urinalysis - check for asymptomatic bacteriuria
● Give all possible differentials for missed menses for this particular pt. ● URINALYSIS!!!! - asymptomatic bacteriuria
○ Hyperthyroidism, etc ● Diabetes screening (FBS, HBa1c) - d/t increased risk of filipinos for gdm
● Make sure to know rationale for requesting ancillaries ● HIV test - if high risk lang to dibaa
● RPR/VDRL (for syphilis)- and this
● HbsAg (but can be done at 3rd tri)
● Early ultrasound to determine age (Crown-Rump length), confirm
pregnancy, location and number (Transvaginal: if <12 weeks AOG
Transabdominal: if >12 weeks AOG)
○ Presence of gestational sac at 4-5 weeks. Yolk sac 5.5 weeks
○ Location of preg (to establish if pregnancy is intrauterine)
○ Number of fetus
UTZ FINDINGS =
CRL = AGE OF GESTATION
LOCATION
FETAL HEART TONES - 10-11wks
NUMBER OF FETUS
ASYMPTOMATIC BACTERIURIA - stasis!

● Compression of the bladder by the uterus also progesterone!- more
on latter part of pregnancy
● URINARY STASIS BC OF PROGESTERONE- DILATION of ureter
● [JZM]: Progesterone-induced dilatation and hypomotility in ureters and
bladder → hypotonicity and hydroureter → recurrent asymptomatic
bacteriuria
Prescription
• Folic Acid 400mcg 1 tab OD until end of first trimester (14 weeks)
- Prevent neural tube defect
• Milk 1 glass OD (not given because patient still presents with nausea)
Monitor danger signs of pregnancy
10. Persistent HEADACHE- preec

11. BLURRING OF VISION -
12. PROLONGED VOMITING increased hcg -> molar preg maybe may lead to
hyperemesis gravidarum -> dehydration, severe electrolyte loss
13. FEVER - infection
14. NONDEPENDENT EDEMA - preeclampsia-
15. EPIGASTRIC/RUQ PAIN - cholecystitis? Preeclampsia, hellp?
● [JZM]: Hypogastric Pain - Threatened abortion
16. DECREASED FETAL MOVEMENT(18-20 wks) - IUFD, abortion (later date
18-20weeks)
17. DYSURIA - UTI
18. BLOODY VAGINAL DISCHARGE - possible abortion, or inc discharge esp
with pruritus
19. WATERY VAGINAL DISCHARGE - pprom?
SUDDEN SEVERE HYPOGASTRIC?? ABORTION

For 2nd tri:
● Ferrous sulfate 325mg/tab 1 tab orally once a day 30 minutes before meals
● Multivitamins 1 tab once a day
PAG LUMABAS NA RESULTS!!! NG LABORATORY

given all labs are normal
Follow up! After labs!

Every 4 weeks until 28 weeks AOG
Every 2 weeks 28-36 weeks AOG
Weekly 37 weeks AOG onwards
ADMITTING ORDER - Admit Diet Monitor Investigation/Intervention ADMITTING ORDER SAMPLE - Admit Diet Monitor
Therapeutics Investigation/Intervention Therapeutics

cc/hr
LABS
MEDICATIONS Medications should include name, dose, route
CALL HO

LABS LABS
Ex. if HR <60 bpm

Postpartum checkup and family planning

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NAME: Gemma Cruz AGE: 21 DATE: August 24, 2021

BIRTHPLACE: QC CIVIL STATUS: Married # OF YEARS RELIGION: Catholic

OCCUPATION: Housewife EDUCATION: NATIONALITY: Filipino

CC: POSTPARTUM CHECKUP, FAMILY PLANNING

HISTORY OF PRESENT ILLNESS:

Breast feeding? Normal ba cycle?

ASSOCIATED SYMPTOMS: SA ROS DAW PO ITO IASK

1. G1(2021) Preterm girl, scheduled CS due to placenta previa

MENSTRUAL HISTORY SEXUAL HISTORY

INTERVAL Regular, 28-30 days NO. OF SEXUAL

SYMPTOMS none DYSPAREUNIA

Please show solution here: GYNECOLOGIC HISTORY (if needed):

PAST MEDICAL AND SURGICAL HISTORY FAMILY HISTORY

IMMUNIZATION COVID-19 vaccine during pregnancy

SOCIAL HISTORY PREVIOUS PRENATAL CHECKUP

ALCOHOL none WHERE

DRUGS none FREQUENCY > 10x

SKIN, HAIR, NAILS

FOCUSED PHYSICAL EXAM: (ASK PX TO VOID FIRST)

PERTINENT POSITIVE PERTINENT NEGATIVE

BASIS FOR THE DIAGNOSIS:

ANCILLARIES: TREATMENT/ PLANS AND FOLLOW UP DATE:

LACTATION AMENORRHEA METHOD (LAM)

If patient wants to do mixed breastfeeding, we are left with natural

Calendar method:CALENDAR METHOD

BASAL BODY TEMPERATURE (BBT METHOD)

Barrier method (condom)

ADMITTING ORDER - Admit Diet Monitor Investigation/Intervention Therapeutics

Civil Status: # of years married: Nationality:

Education: Occupation: Religion:

Chief Complaint: Comments/Suggestions

Pregnant/suspicious of Amenorrhea, Pain, Discharge and Bleeding Prenatal/follow-up: Pt was brought in

Signs of labor: ● UTZ: CRL (12), AOG, location of fetus, placenta

If Pregnant AOG: EDC:

2015 Term NSD none

2nd NSD none

3rd NSD none

Personal/Social/Past Medical Hx Comments/Suggestions

Sexual hx Coitarche *skip*

Personal & Social hx Smoking *skip*

Review of Systems Comments/Suggestions

*OMIT some of these if already asked in HPI* *skip*

10 Danger Signs (for

Physical Exam Comments/Suggestions

General Mental Status Conscious coherent stretcher borne

Vitals BP (140/90; Sev - 160/110) BP 90/60

HEENT Conjunctiva Pale palpebral conjunctiva

Cardio Precordium Dynamic precordium

Respi Chest Expansion Symmetrical *skip*

Breast *ask for consent first* *skip*

Pelvic External Genitalia Moderate to profuse vaginal bleeding Any lacerations?

Speculum (no need to be done in F. check-ups,

Internal (NO in Previa)

Rectal PID, Endometriosis, Endometrioma

Clinical Impression Comments/Suggestions

G4P4 (4004), postpartum hemorrhage secondary to uterine atony,

RULE IN RULE OUT

Ancillaries For Baseline ABCs first Check presence of

● CBC - to check severity of blood loss; we

Treatment 1st trimester Step by step management for uterine atony

2nd: Ask for help. Do Bimanual compression +

Carboprost 250 ug Hypertension

Sexual hx Coitarche skip

Personal & Social hx Smoking skip

OMIT some of these if already asked in HPI skip

Respi Chest Expansion Symmetrical skip

Breast ask for consent first skip

Uterine packing - not effective