e P re s e nt a t i o n

C a s
SEVILLA, LOREANNE NOVEM
SILIM, MIRIAM GRACE D.
IDENTIFYING DATA
• 27 y.o.
• G1P0
• Filipino
• Single
• Roman Catholic
• Balugo,Dumaguete City, Negros Oriental

CC: labor pains

History of Present
Illness
 17 • Had onset of labor pains located on the
hypogastric area that radiates to the lower
HOURS back, PS 3/10, uterine contractions lasts 30
seconds with an interval of 5 mins., relieved
by walking, no bloody show, intact bag of
PTA water
 • Patient sought admission, and an internal exam was
9 IE:
done:

• Dilation: 3-4 cm
HOURS • Effacement: 70-80%
• BOW: Intact BOW
• Station: -3
PTA • Presentation: Cephalic
(+) regular contractions every 5-10 min that lasts 60 seconds
• Patient was advised to go home
 • Persistent labor pains, not relived by walking.
• Patient sought admission, and an internal exam was

HOUR IE:
done:

• Dilation: 4-5 cm
PTA • Effacement: 80%
• BOW: Intact BOW
• Station: -2
• Presentation: Cephalic
(+) regular contractions every 5 min that lasts 90 seconds
• Patient was then admitted
 Obstetric History
• OB Score: G1P0
• Current Pregnancy
LMP: December 29, 2021
EDC: 10/6/2021 by 1st trimester UTZ
AOG: 38 2/7 weeks by eUTZ
 Maternal History
• Pregnancy detected thru PT; confirmed thru TVS at 8 wks AOG
• First prenatal visit at 8 wks AOG with an ObGyn; Routine exams were all unremarkable
• Prenatal vitamins:
• FeSo4 (Sorbifer) 1 tab OD
• Multivitamins + Minerals (Molvite) 1tab OD
• Regular prenatal check-up
• Monthly until 26 AOG
• Every 2 weeks until 34 wk AOG
• Weekly thereafter Was diagnosed with UTI on July and September 2021.
• Unrecalled antibiotics taken once a day for 7
days.
 Gynecologic History
• Menarche: 12 y.o. • Coitarche: 22 y.o
• Interval: regular/monthly • Partners: 1
• Duration: 5 days • Contraceptive: None
• Amount: 3-4 pads/day; • Pap smear: None
moderately soaked • STIs: None
• Symptoms: None
 Past Medical History
(-)hypertension
(-)diabetes mellitus
(+)bronchial asthma
(+)Allergies: eggs, chicken, sea foods
 Family History
• (+)hypertension- paternal
• (+)diabetes mellitus- maternal & paternal
• (+)bronchial asthma- maternal
• (+)cancer- paternal side/grandmother (Cervical Ca)
 Personal and Social History
• Non-smoker, non-alcoholic beverage drinker, denies
use of illicit drugs
 Review of Systems
General Skin HEENT Respiratory

(-) fatigue (-)pruritus (-)headache (-)dyspnea

(-) loss of appetite (-)dizziness (-)cough
(-)blurring of
vision

Cardiovascular Gastrointestinal Genitourinary Hematologic

(-)chest pain (-)nausea/vomiting (-)dysuria (-)easy bruising

(-)palpitations (-)anuria
(-)orthopnea (-)hematuria
 Physical
Examination
Awake, ambulatory, coherent, not in respiratory distress

BP:120/90 mmHg
HR: 95 bpm

Ht: 154 cm
RR: 22 cpm
Temp: 37.7 C
SpO2: 98%

Wt: 69.5 kg
 Skin No pallor, no active lesions; warm, moist, with good turgor

HEENT Normocephalic, anicteric sclerae, pink palpebral

conjunctivae; nasal septum in midline, no nasoaural
discharge; tongue at midline, pink dry lips

Neck Trachea at midline, no lymphadenopathies

Chest/Lungs Symmetric chest expansion, clear breath sounds

 CVS PMI at 5th ICS LMCL, regular rate
and rhythm, no murmurs
Leopold’s Maneuver
L1- breech
Breast No erythema, no discharges on L2- R: fetal small parts
nipples, no tenderness L: fetal back
L3: Not engaged
L4: cephalic

Abdomen Gravid, (+) striaes

FH: 32 cm
EFW: 3100 g
FHT: 130 noted at LLQ
UC: Contractions every 5 min
lasting 90 seconds
Extremities No gross deformities, Grade 1
pitting edema, strong peripheral
pulses, CRT<2 sec
Internal Examination
Dilatation: 4-5 cm
Effacement: 80 %
Station:-2
Bag of water: intact
Consistency: Medium
Position: Posterior
 Admitting
Impression
G1P0 PU 38 2/7 weeks AOG by eUTZ, cephalic presentation, in active phase of labor