CASE STUDY

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

: 032 ± 6 HEALTH HISTORY I. There was an also noted uterine contraction occurring at 2 minutes interval. S + -1. 2012/ 8: 30am Sex: Female Civil status: Single Religious Affiliation: Catholic Ethnic Group: Ilocano Contact No. IV. She had her prenatal check-up six times. patient had hypogastric pains and lumbosacral pain. admits tip of finger. No associated rupture of membranes. Few minutes prior to admission. : 09199786051 Relationship: Mother Nationality: Filipino Admitting Physician: Dr. Pangasinan Next of Kin: Elena Hare Educational Attainment: 3rd year college Attending Physician: Dr.PATIENT¶S PROFILE Name: HARE. Consultation was done where an IE revealed a posterior cervix. Laika Grace Madarang Age: 20 years old Birthdate: September 15. Pangasinan Address: Agat. III. There was also a cessation of abdominal pain. Past Medical History: Patient claimed to have no previous hospitalization and surgeries. Chief Complaint: Labor pain History of Present Illness: 28 hours prior to admission. Prenatal History: Patient was cognizant of pregnancy at 5 weeks age of gestation due to amenorrhea. Pregnancy test was done at home revealing a (+) result. no noted vaginal discharge. Sison. . a BPPS was done which revealed a grade 2 placenta and an EFW of 2.4 kg. Viado Room No. Alice Salvador Date & Time Admitted: January 25. II. CTE was also done which was normal. 1 minute in duration. 1991 Birthplace: Sison. severe in intensity.

Sexual History: Patient claimed that her 1st sexual contact was at the age of 16 years old. . She is living with her parents at Sison. Gyne History: Patient had no gynecological illness in the past. Last sexual contact was last November 2011. Subsequent contacts were comfortable. She also claimed that she is gambling. X. She claimed to have dysmenorrhea and subsequent menses were irregular at 28 cycles for 6 days. OB History: OB score: G1 ± Present pregnancy. 4 days duration. (+) dyspareunia. CVP. Menstrual History: Patient had her menarche at 13 years old. consuming 2-3 moderately soaked pads per day. (+) dyspareunia. Pangasinan. IX. Asthma. DM. VIII. (+) family planning. and (-) Pap smear. (-) bleeding. (+) bleeding. VI. Claims to have 1 sexual partner.V. Family History: No Hypertension. Twinning. VII. Social & Environmental History: Patient is not smoking but she is drinking alcoholic beverages before pregnancy.

Sign up to vote on this title
UsefulNot useful