CASE STUDY PROPER

a. GENERAL INFORMATION
NAME: XXX
AGE: 32 years old
SEX: Female
ADDRESS: Phase 2 Ruby St. Mary Homes Subd., Brgy. Molino, Bacoor, Cavite
BIRTHDATE: August-13-1971
CIVIL STATUS: Married
DATE OF ADMISSION: September 29, 2015
TIME OF ADMISSION: 12:20 P.M
CHIEF COMPLAINTS: Labor with Contraction
INITIAL DIAGNOSIS: G4P3; Normal Spontaneous Delivery accompanied by
Pre-Eclampsia
FINAL DIAGNOSIS: Normal Spontaneous Delivery with Episiorraphy
b. OBSTETRICAL HISTORY
LMP-January 15, 2015
EDD- October 27, 2015
T-3
P-0
A-0

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L-3
Previous Pregnancy-3
Caesarean Section- No
Still Birth-No
Post-Partum Hemorrhage- No
3 Consecutive Miscarriages- No
Tetanus

1st dose

2nd dose

3rd dose

4th dose

5th dose

Toxoid
Date

2008

2008

2012

2013

July 20,
2015

c. PAST HEALTH HISTORY

The patient was experienced her first hospitalization and was admitted on
2009 to deliver her 1st baby. And on the year 2012 she was delivered to her 2 nd baby.
On the year 2013 she was admitted and delivered her 3 rd baby.

d. PRESENT HEALTH HISTORY

Mrs. XXX was her last menstrual period on January 15, 205 and during
her 1st trimester she had a 2 check ups: 1 st visit in the clinic on March 10, 2015 and her
weight is 63kg also her BP is 110/70 mmHg and she is in the 2 nd month of pregnancy.
Her 2nd visit on April 22, 2015 she is on the 3 rd month of pregnancy, the weight is 59 kg
and her BP is 110/80 mmHg. On the 2 nd trimester of pregnancy she had a complete
check-up every month. On the 4th month of pregnancy her BP is 110/90 mmHg and
weight is 60kg. In her 5th month of pregnancy her BP and weight was 120/70mmHg and
66kg. While on her 6th month her BP was 120/70mmgHg and her weight is 65kg.
During the 3rd trimester she had a check-up on September 16, 2015 and her weight was
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66kg. During the entire of her pregnancy she has not complained for the vaginal
discharges, urinary tract infection, fever, signs of pallor and her laboratory results is ok.
On September 29, 2015 she was admitted at St. Marys Lying-In Clinic, and she
complained of labor pain. After being examined seen by her attending midwife, she has
a high blood pressure and bipedal non-pitting edema. Upon internal examination 45cms dilated of cervix, the membranes are intact, no vaginal bleeding, the contraction is
active and 5 in 10 minutes duration, the fetal heart rate was 132bpm, the temperature is
36.7oC and BP is 170/100mmHg.

e. PHYSICAL ASSESSMENT

General Survey:
Our patient, Mrs.XXX, 32 years old was assessed on September 29, 2015. She
was admitted at St. Mary Lying-In Clinic. She weighs 68kg. Patient was received
conscious, coherent and responsive. She cooperates and participates in our physical
assessment.
Vital Signs:

Date/ Time
BP (mmHg)
Temperature
(oC)
PR (bpm)
RR (bpm)

1:30 P.M
170/100
36.7

3:30 P.M
160/110
37.1

5:45 P.M
160/100
36.1

11:30 P.M
150/110
37.1

1:30 A.M
150/100
36.1

95
20

85
19

94
18

95
19

115
19

SKIN

brown skin generally uniform in color except in areas exposed to the sun
skin temperature uniform and within the normal range (37C)
when pinched, skin readily springs back to previous state
moist skin folds
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nails with smooth texture

nail beds pink
prompt capillary refill time (2 seconds)
bipedal non-pitting edema

absence of nodules or masses

symmetric facial features and movements
symmetric nasolabial folds
evenly distributed black hair
no infestations

eyebrows symmetrically aligned with equal movement

eyelashes equally distributed and curled slightly outward
skin of eyelids intact with no discoloration
lids close symmetrically
bilateral blinking exhibited
no discharge, edema or tearing
white sclera
pink palpebral conjunctiva
iris black in color
pupils equal in size with smooth borders
illuminated pupils constricts
pupils converge when near object is moved toward the nose
when looking straight ahead, the client can see objects in the periphery
both eyes coordinated, move in unison with parallel alignment

color same as facial skin

symmetrically aligned
pinna immediately recoils after it is folded
pinna is not tender
no lesions or discoloration
dry cerumen, grayish-tan color
normal voice tones audible
able to hear ticking of a watch in both ears

HEAD

EYES

EARS

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NOSE

symmetric and straight

no discharge or flaring
absence of lesions and tenderness
nasal septum intact and in the midline

MOUTH AND THROAT

outer lips uniform pink color with symmetric contour, soft and moist
buccal mucosa is of uniform pink color
gums are pink
tongue pink, moist, at central position

head centered
lymph nodes not palpable

NECK

BREAST

firm
generally symmetric in size

Engorged breast

CARDIOVASCULAR

BP 170/100 mmHg
PR 95 bpm
reported palpitations
symmetric pulse strength

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RESPIRATORY/CHEST

chest symmetric
chest wall intact, no tenderness, no masses
symmetric chest expansion and excursion
RR: 20 breaths per minute

GASTROINTESTINAL/ABDOMEN

striae present at hypogastric and iliac regions

linea nigra present
no tenderness

URINARY

absence of nocturia, dysuria, urgency, hesitancy,

light yellow urine

REPRODUCTIVE

regular menstrual cycle

G4P3

MUSCULOSKELETAL/EXTREMITIES

muscle equal size on both sides of the body

no bone deformities
no tenderness

NEUROLOGIC

can respond to verbal commands

oriented
conscious
displayed anxiety
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f. COURSE IN THE WARD

March 10, 2015
The midwife was ordered Clusivol OB.
April 22, 2015
The midwife was ordered Folic Acid, Vit.C and Ferrous Sulfate.
May 23, 2015
The midwife was ordered to continue Ferrous Sulfate and advised to have a
laboratory diagnostic test such as Hematology, Urinalysis, Clinical Chemistry and
Ultrasounds.

July 20, 2015

The midwife injected the 5th dose of tetanus toxoid.
August 23, 2015
She ordered cephalexin 500 mg for 7 days.
September 16, 2015
The midwife was no ordered given to the patient.
September 29, 2015
The midwife ordered Normal Saline IV 1L 20 drops per minutes. She injected
hyoscine and oxytocin.
September 30, 2015
The midwife ordered May Go Home and she schedules the follow up check-up
October 7, 2015.
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