Lyceum Northwestern University

Dagupan City, Pangasinan

College of Medicine
Department of Obstetrics and Gynecology

History Taking

Kumar Rahul

III/A

Group-7

General data
Date of Interview: November 11, 2022
Time of history:1 pm
Informant:Patient
Reliability:90%

This is a case of patient SAD,a 39 year old, Married, house wife and resides at
Bugallon,Pangasinan. She is a Filipino Citizen and Roman Catholic, born on March
29,1982 at Dagupan City, Pangasinan. Patient was admitted to R1MC Binloc on
November 7, 2022.

Chief Complaints

Loose stools

HISTORY OF PRESENT ILLNESS

The patient’s condition started:
4 days PTA, the patient in her 37 weeks of gestation felt an intermittent pain in her
epigastric region associated with cramping pain which radiates from the center of
abdomen up to the thigh with a pain scale of 5/10. The pain is alleviated by walking
and aggravated by talking and side-lying. Associated signs and symptoms such as
frequent diarrhea (4 times a day) with few, little mucus-like bloody stools,
bloatedness and flatulence were noted. No noted fever, headache or vomiting.
1 hour PTA, the patient didn’t take any medications also Persistence of epigastric
pain and frequent diarrhea prompted her to seek consultation. Hence, admission

PAST MEDICAL / SURGICAL HISTORY

Patient SAD’s childhood immunizations were completed, she had her COVID19
vaccine (AstraZenecaⓇ) 2 doses and had her first booster dose of (PfizerⓇ).
No allergy to food, medication, pollens fur, or dust,
No known childhood illnesses and adult illness noted.
No history of hospitalization and surgery procedures.

OBSTETRIC and GYNECOLOGIC HISTORY

OBSTETRIC

The patient had her last menstrual period last March 27, 2022. The patient is
currently in her 37 weeks of gestation, singleton, live, intrauterine pregnancy for her
7th child and the expected date of delivery is December 30, 2022.

Gravida: 7 Parity:6
Term: 6
Preterm:0
Miscarriage:0
Living children: 4

OB YEAR AOG GENDER MANNER LOCATION COMPLICATION

SCORE OF
DELIVERY

G1 2004 Term F NSVD Hospital Epileptic

G2 2008 Term M NSVD Hospital None

G3 2010 Term M NSVD Hospital None

G4 2015 Term M NSVD Hospital None

G5 2017 Term F NSVD Hospital None

G6 2018 Term M NSVD Hospital None

GYNECOLOGIC

Pregnancy symptoms of the patient were not mentioned. Prenatal Check up not
mentioned.

MENSTRUAL

Menarche: 16 y/o

Interval: Regular, 28-30 day cycle

Duration: 4 Days

Amount: Normal Flow, 3-4 pads/day

Menstruation is associated with dysmenorrhea

SEXUAL

Her first coitus was 20 years old with only 1 sexual partner. No symptoms noted.

CONTRACEPTIVE

The patient does not take any birth control methods.

FAMILY HISTORY
The patient's father is already deceased, mother is diagnosed with asthma and still
alive.Brother is noted with medical incapacity -deaf- mute.

No other known medical problems in blood relatives in both maternal and paternal
side such as Cancer, Hypertension, Diabetes, Tuberculosis, Heart Disease, Stroke,
Kidney disease, Arthritis, Blood disorder, Asthma, Epilepsy, Mental disorder and
gallbladder disease. Also no known Multiple Gestation noted within the family.

Children and husband have no recorded medical problems.

PERSONAL AND SOCIAL HISTORY

PERSONAL

The patient with her husband has been married for 22 years, having 6 healthy
Children. Patient finished Elementary and works as a housewife.

SOCIAL

The patient had never smoked and never drunk alcohol. Her diet usually consists of
a meal and eats 2 to 3 times a day with no food preference. She drinks coffee only
once a day and no nutritional supplements are taken. She sleeps for about 8 to 10
hours a day and takes a jog in the morning. She usually does her household chores
as her form of daily activity. Her source of stress is when her husband gets drunk
and usually does not talk to him.

ENVIRONMENTAL

The patient resides for 30 years at Bugallon, Pangasinan in a 2 floor Kubo house
with 1 room along with her 4 children and her husband. The source of their drinking
water is from minerals, garbage disposal is through compost pit and faecal disposal
is through septic tank (toilet without flush). Patients do not own any pets and the
state of the neighbourhood is quite noisy.
REVIEW OF SYSTEMS

General: (-) fever

(-) chills

(-) malaise

(-) fatigue

(+) weight gain due to pregnancy

Skin: (-) lesions,

(-) jaundice,

(-) hematoma,

(-) rashes,

(-) hair loss,

(-) pruritus,

(-) pallor

(-) cyanosis,

(-) color change,

(-) dryness
HEENT:

Head: (-) headache, Gastrointestinal: (+) abdominal pain

(-) dizziness, (-) dysphagia,

(-) syncope, (-) diarrhea,

(-) lesions, (-) constipation,

(-) hair loss (-) heartburn,

(-) nausea,

(-) hemorrhoid,

(-) change in bowel

habit,

(-) excessive
belching/passing of gas,

(-) melena,

(-) hematochezia
Eyes: (-) photophobia, Genito-urinary: (-) nocturia,

(-) pain, (-) dysuria,

(-) double vision, (-) polyuria,

(-) visual difficulties (-) oliguria,

(-) blurred vision, (-) hematuria,

(-) lacrimation (-) incontinence,

(-) urinary retention,

(-) flank/supra pubic

pain,

(-) passage of stone,

(-) discharge

Ears: (-) deformities, Musculoskeletal (-) numbness on both

: feet,
(-) hearing
problem, (-) muscle pain, (-)
backache,
(-) tinnitus
(-) joint pain,
(-) discharge
(-) swelling on both feet,

(-) redness,

(-) deformities,

(-) weakness
Nose: (-) sense of smell Neurologic: (-) paralysis,
problem,
(-) numbness,
(-) sneezing,
(-) seizure,
(-) discharge
(-) tremors,
(-) itching,
(-) language problem,
(-) epistaxis,
(-) memory loss
(-) obstruction,

(-) polyps

Mouth and (-) dysphagia Endocrine: (-) polyphagia,

Throat
(-) sore throat, (-) heat or cold
intolerance
(-) bleeding gums,
(+) polydipsia
(-) dry mouth

Neck: (-) pain, Hematological: (-) easy bruisability,

(-) swelling, (-) pallor

(-) stiffness,

(-) lumps
 Cardiovascular (-) chest pain,

(-) orthopnea,

(-) palpitation,

(-) edema,

(-) easy fatigability

Respiratory: (-) dyspnea,

(-) chest pain,

(-) back pain,

(-) orthopnea,

(-) back pain,

(-) hemoptysis,

(-) cough,

PHYSICAL EXAMINATION

General survey

Patient is awake, responsive, cooperative, coherent. oriented to time, place, and

person.speech is clear and it’s on normal pitch and normal pace. There are no signs
of respiratory distress.

BP= 110/90 mm Hg; sitting

CR = 103/ min : regular
RR= 20 / min : normal
Temp =36.6 oC: axillary
Sp02 = 96%
Ht = 123cm
Weight: 50 kg
BMI: 33.0

Skin : Skin is brown, moist and warm, smooth and with good skin turgor and no
abnormal pigmentation.

Head: the skull is normocephalic/ atraumatic. Hair with good texture.No edema,
bruises, and mass noted.

Eyes : Anicteric sclera, Pupils are constricting, equally round and reactive to light
and accommodations, with pink palpebral conjunctiva. Disc margins sharp; no
hemorrhages or exudates.

Ears :External ears normal, no lesions or deformities; canals clear bilaterally,

tympanic membranes intact with good movement, no fluid; hearing grossly intact
bilaterally.

Nose : External nose normal, no lesions or deformities; nasal mucosa, septum, and
turbinates normal

Throat : Oral mucosa pink, dentition good, pharynx without exudates. Tongue is on
the midline Teeth incomplete – 4 removed( 2 canine and 2 frontal)

Neck : Neck is supple, no masses, trachea midline; no thyroid nodules, masses,

tenderness, or enlargement

Chest/ Lungs : symmetrical, no retractions, no lag; , no spider angiomas; equal vocal

and tactile fremitus ; equally resonant on both lung fields; equal breath sounds, no
rales and wheezes noted.

Abdomen: Globular, presence of linea nigra, presence of striae gravidarum, no

masses; normal bowel sounds,no lesions,no discoloration,

Fundic height: 27 cm

Fetal heart tone:140bpm

L1- round, nodular, firm in the fundal area

L2- hard and resistant structure felt at the left side, small movable parts at the
maternal side.

L3 – binodular and movable (ballotable) not engaged

L4- not applicable.

FETAL presentation: Cephalic .

Extremities: No leg length discrepancy, muscle strength of 5/5 on both upper and
lower extremities, Normoreflexia on both upper and lower extremities, Good
peripheral pulse equal and regular on both upper and lower extremities.

Radial Femoral Popliteal Dorsalis Pedis Posterior Tibialis

Right 2+ 2+ 1+ 2+ 2+

Left 2+ 2+ 1+ 2+ 2+

Rectal exam: NOT DONE

Genitalia :External: grossly normal, symmetrical hair distance, no lesions noted

Speculum Examination: cervix is closed, no bleeding, uneffaced

Neurologic exam : Patient is well oriented to time and can speak normally with no
memory loss and is able to recall every word. GCS 15 E4V5M6.

INITIAL ASSESSMENT
INFECTIVE COLITIS- AMOEBIASIS (ENTAMOEBA HISTOLYTICA) OR
ESCHERICHIA COLI

BASIS
(+) LOOSE STOOLS (+) travelling
(+) BLOOD IN STOOL (+) contaminated items

(+) Abdominal pain (+) poor sanitary conditions

(+) bloatedness

(+) flatulence

DIFFERENTIAL DIAGNOSIS

RULE IN RULE OUT

ulcerative colitis (+) Abdominal pain (-) Rectal pain

(+) Bloody diarrhea (-)Fatigue

Inflammatory bowel disease (+) Bloody diarrhea (-) Fever

(+) abdominal pain (-) Vomiting

Ischemic colitis (+) blood in stool (-) weight loss

(+) abdominal pain (-) Nausea

TREATMENT & MANAGEMENT

Medication MOA DOSAGE SIDE

EFFECT
Oral rehydration the ability of glucose to stimulate 2200-4000ml(1 hypernatremia
Na and fluid absorption in the small 5 years and
intestine over)

Intravenous ● produces a metabolic 5 mEq/ml Backpain,

fluids(ringers lactate) alkalinizing effect. (560 mg/ mL) bluish colour
● Lactate ions are of the skin,
metabolized ultimately to blurred vision,
carbon dioxide and water, chest pain,
which requires the cough.
consumption of hydrogen
cations.

metronidazole Metronidazole has activity Stomach pain,

against protozoans like difficulty in breathing,
Entamoeba histolytica, pounding heartbeat
Giardia lamblia and and headache.
Trichomonas vaginalis.

ciprofloxacin targeting of the alpha fever, sore throat,

subunits of DNA gyrase burning in your eyes,
prevents it from skin pain, red or
supercoiling the bacterial purple skin rash that
DNA which prevents DNA spreads and causes
replication. blistering.

Amoxicillin-clavulanic preventing bacteria from pain or tenderness in

acid destroying amoxicillin. the upper stomach,
Antibiotics will not work for pale stools, dark
colds, flu, or other viral urine, loss of appetite,
infections nausea, vomiting, or
yellow eyes or skin.

FINAL IMPRESSION

G7P6 (6004) PU 37 WEEKS AOG INFECTIVE COLITIS- AMOEBIASIS

(ENTAMOEBA HISTOLYTICA) OR ESCHERICHIA COL I