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PRESENTATION
OB PGI
OBJECTIVES
GENERAL DATA
GENERAL DATA
MENSTRUAL HISTORY
OBSTETRIC HISTORY
Obstetric score: G2P0(0010)
Previous Pregnancies:
G1- 2015, Spontaneous abortion,
18 wks AOG
no D/C done
G2- Present pregnancy
LMP: April 26, 2016
EDC: January 31, 2017
AOG: 29 2/7 Weeks
PRENATAL HISTORY
CBC
U/A
HbSAg
Blood typing,
FBS, 75 g OGTT,
Papsmear
PRENATAL HISTORY
PELVIC UTZ (11/17/16 )
Pregnancy Uterine, at 28 weeks 6 days (+/- 2
weeks) by fetal biometry, live ,singleton , cephalic
presentation.
Placenta right anterofundal, grade 2 highlying.
Low normal amniotic fluid volume/ borderline
oligohydramnios (AFI=7.4 cm).
EFW is withing the 10 th-90th percentile of the
normal growth curve pattern for a 28 week fetus.
Cervical funneling noted with cervical length of
1.7 cm
Slightly increased
100-g
glucose
FASTING
5.2 mmol/L
Within normal
1 HR
9.2 mmol/L
Within normal
2 HR
9.4 mmol/L
8.8 mmol/L
Slightly increased
3 HR
Slightly increased
PRENATAL HISTORY
URINALYSIS
- gross: Light yellow, hazy
- ph: 6
- specific gravity: 1.010
-Protein: NEGATIVE
-Glucose: NEGATIVE
-Microscopic
-RBC: 0-1 /HPF
-WBC: 0-2/HPF
-Epith.: moderate
-Bacteria: few
PRENATAL HISTORY
CBC
-WBC: 13.83x 10 ^9/L
-HGB: 124 g/L
-HTC: 0.36 L/L
-RBC: 4.12
-PLT: 254 x 10 ^9/L
-Neutrophils: 84.70
-Lymphocytes: 11.90
-Monocytes: 3.20
-Eosinophils : 0.10
-Basophils: 0.10
PRENATAL HISTORY
HbSagNonreactive
Bloodtype- A
(+)
PRENATAL HISTORY
Medications
Folic acid tab OD PO,
Ferrous sulfate tab OD PO
Diet:
2 glasses of milk per day
1 banana per meal
PRENATAL HISTORY
Frequent travel within Cebu
province noted
Occasional coitus with partner
noted
Last PNC- November 16, 2016,
29 1/7 wks AOG
CONTRACEPTIVE
HISTORY
SEXUAL HISTORY
Coitarche- 14 years old
5 partners
No dyspareunia
No post coital bleeding noted
FAMILY MEDICAL
HISTORY
History of Hypertension and
Diabetes mellitus in the
paternal side
No history of asthma,
congenital anomalies nor
multifetal gestation noted
CHIEF COMPLAIN
HISTORY OF PRESENT
ILLNESS
HISTORY OF PRESENT
ILLNESS
HISTORY OF PRESENT
ILLNESS
Review of Systems
Review of Systems
PHYSICAL EXAMINATION
GENERAL SURVEY
VITAL SIGNS
HEAD
Inspection:
normocephalic,
no lumps
lesions, or deformities
Palpation:
no masses, no tenderness
EYES
EARS
Inspection:
symmetrical; no deformities; no lesions, no
discharges, no swelling or redness
Palpation:
no masses or lumps, no tenderness on
mastoid area, no pain when ear is tugged
Otoscopy:
no discharges, few cerumens seen, tympanic
membrane is pearly white and intact; not
retracted or bulged
Auditory exam:
patient can hear whispered words
NOSE
Inspection:
symmetrical,
no deformities, no
lesions, nasal mucosa is pinkish.
Nasal septum is midline and not
perforated; no swelling or redness
Palpation:
No tenderness, no masses or lumps
Sinuses:
maxillary and frontal sinuses are not
tender;
(+)
red
glow
upon
Inspection:
Lips: no deformities, pink, no lesions, dry
Buccal mucosa: no ulcers; moist
Gums: no lesions, pink, moist
Tongue: midline; no fasciculations; no
ulcers
Hard and soft palate: no masses; no
lesions, no ulcers
Uvula: midline
Pharynx: no swelling or inflammation
Tonsils: symmetrical, no inflammation, no
NECK
Inspection:
trachea is midline; no lesions,
no scars
Palpation:
no
lymphadenopathy,
no
nodules; thyroid not palpable
right and left carotic pulsations
good; thyroid cartilage and
cricoid, rises together upon
BREASTS
Inspection:
no lesions, no inflammation, no
dimpling, no abnormal nipple
discharges, no deformities
Palpation:
no
masses or lumps, no
lymphadenopathy;
no
tenderness
Inspection:
no
gross
chest
deformities,
no
asymmetry,
no
abnormal
chest
retractions; no accessory muscles used
in breathing
Palpation:
no tenderness on chestwall; equal chest
expansion
Percussion:
resonant sounds on lung fields
Auscultation:
CARDIOVASCULAR
SYSTEM
Inspection:
no
gross chest deformities; no visible
pulsations
Palpation:
maximum point of impulse on 5th intercostals
space 5-7cm lateral to midsternal line with
small amplitude
Percussion:
not performed
Auscultation:
apex beat heard in 5th intercostals space 5-7
lateral to the midsternal line; good S1 and S2;
ABDOMEN
Inspection:
gravid, round and protuberant, no
swelling, no observable masses,
(+)
linea
nigra;
(+)
striae
gravidarum
No organomegaly noted
FH: 20cm
FHT: 140 bpm
Hyperpigmen
ted areolar
Distended
abdomen, size of
29 weeks gravid
FH = 20cm
Linea nigra
striae
ABDOMEN
Abdomen
Palpation:
Leopolds Maneuver
L1 breech
L2 fetal back at maternal left side;
fetal
extremities at maternal right side
L3 cephalic
L4 floating
FHT 140 bpm
PELVIC EXAM
Dilatation: 2cm
Effacement: slightly effaced
Position: midposition
PELVIC EXAM
PRESENTATION:
Membranes: intact
Station: -3
Fluid: clear
Adequate pelvimetry
EXTREMITIES
Inspection:
no gross deformities; symmetrical;
parallel to each other; no swelling,
no redness, no inflammation or
lesions; not cyanotic; no edema
Palpation:
warm to touch, no tenderness
Range of motion:
full
NEUROLOGIC EXAM
NEUROLOGIC EXAM
Cranial nerves:
1: able to smell perfume
2: good visual acuity; able to read nameplate
2, 3: (+) near response test; (+) consensual and direct
papillary reflex
3, 4, 6: intact 6 cardinal directions of gaze
5: able to clench teeth with temporal contractions; intact
facial sensation
7: appropriate facial movements; (+) taste on anterior
2/3 of tongue
8: can hear whispered words both ears; intact balance
9, 10: (+) gag reflex; equal palatal elevation
11: equal shoulder shrug; good sternocleidomastoid
strength
NEUROLOGIC EXAM
Motor:
5/5 on both upper and lower extremities; no
fasciculations, no rigidity; no flaccidity; no
tremors
Sensory:
able to feel pain, temperature, light touch, and
vibration; intact position sense
Reflexes:
+2 all extremities
Cerebellar signs:
(-) ataxia, (-) dysmetria, (-) dysdiadochokinisia
Meningeal Signs:
LOGICAL IMPRESSION
GESTATIONAL DIABETES
POINTS TO SUPPORT:
FBS = 128MG/dL
100g OGTT
2-hr
= 9.4 mmol/L
3-hr = 8.8 mmol/L
COURSE
IN THE
E.R.
COURSE IN THE ER
SOAP
Day 0 (11/17/16)
S - Patient was seen and examined.
- Patient complained of hypogastric pain
radiating to the flank area with a pain scale
of 6/10 associated with irregular uterine
contractions with 3-4min interval lasting for
40-50secs.
- No episodes of vomiting, fever and dyspnea.
COURSE IN THE ER
SOAP
Day 0 (11/17/16)
O - Vital Signs
COURSE IN THE ER
SOAP
Day 0 (11/17/16)
O Inspection:
No organomegaly noted
FH: 20cm
COURSE IN THE ER
SOAP
Day 0 (11/17/16)
O Abdomen
Palpation: Leopolds Maneuver
L1 breech
L2 fetal back at maternal left side;
fetal
extremities at maternal right side
L3 cephalic
L4 floating
FHT 140 bpm
COURSE IN THE ER
SOAP
Day 0 (11/17/16)
O CERVIX:
Dilatation: 2cm
Effacement: slightly effaced
Position: midposition
PRESENTATION:
Membranes: intact
Station: -3
Fluid: clear
COURSE IN THE ER
SOAP
Day 0 (11/17/16)
P Medication:
COURSE IN THE ER
SOAP
Day 0 (11/17/16)
P Attach to CTG
COURSE
IN THE
LABOR
ROOM
O - Vital Signs
O Inspection:
No organomegaly noted
FH: 20cm
O Abdomen
Palpation: Leopolds Maneuver
L1 breech
L2 fetal back at maternal left side;
fetal
extremities at maternal right side
L3 cephalic
L4 floating
FHT 140 bpm
O CERVIX:
Dilatation: 8-9cm
Effacement: 70-80% effaced
Position: midposition
PRESENTATION:
Membranes: ruptured
Station: -3
Fluid: clear
RESUL
T
WBC
13.83
INCREASED
HGB
124
WITHIN NORMAL
HCT
0.36
WITHIN NORMAL
MCV
87.6
MCH
30.10
RBC
4.12
WITHIN NORMAL
PLATELET
254
WITHIN NORMAL
NEUTROPH 84.7
IL
INCREASED
LYMPHOCY
TE
DECREASED
11.9
RESULT
COLOR
YELLOW
TRANSPARENC
Y
HAZY
PH
SPEC GRAV
1.010
PROTEIN
NEGATIV
E
GLUCOSE
NEGATIV
E
EPITHELIAL
MODERA
TE
BACTERIA
FEW
P Termination of Pregnancy
Attach to CTG
Monitor fetal heart rate pattern
BABY DATA:
Sex: Male
Weight: 1390g
Length: 38cm
APGAR Score: 8,9
BS: ???
CASE DISCUSSION