Ob Case Write Up

1766 Words Apr 7th, 2011 8 Pages
Identifying Data
JJ is a 38-year old female, Chinese, Roman Catholic, married, residing in Pasig City.

Chief Complaint: vaginal bleeding, 1 day

History of Present Illness
LMP = April 21, 2010 PMP = March 2010 AOG = 27 6/7 weeks EDD = Jan. 26, 2011

The present condition started about an hour prior to consult. The patient while walking around the mall experienced sudden onset of passage of bloody vaginal discharge of unknown quantity. There was no associated hypogastric pain, uterine contraction, or watery vaginal discharge. Patient at the time also noted good fetal tone. The bleeding persisted hence the consult.

Trimester History During the first trimester patient only took multivitamins and folic acid and no other medications. She
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Abdomen is globularly enlarged with a transverse surgical scar at the hypogastric area around 7cms in length. Striae gravidarum are seen below the umbilicus. Linea nigra also observed. The bowel sounds are normoactive. Fundic height is at 27 cm. Fetal heart rate is at 140s. Fundus is occupied by breech, fetal back on the left, small parts on the right, cephalic floating.
Speculum Examination. Obvious pooling of blood tinged fluid; (+) Nitrazine test.
Internal Examination. Normal looking external genitalia, no lesions, no masses, multiparous introitus, vagina fits two fingers easily. No adnexal masses. Cervix is 1 cm dilated, uneffaced cerviz, floating with (-) bag of water. Estimate fetal weight is 2325g.
DRE not done.
Extremities. Full and equal pulses. No edema or cyanosis.

Psychosocial Factors The patient is a yuppie belonging to a family with child. Both her husband and the patient are working for a living as employees. All of the expenses for this pregnancy will be paid for the health-card provided for by their work and partly out of pocket cost. Patient is a second time mother.

Clinical Impression

Pregnancy Uterine 27 6/7 weeks age of gestation, cephalic not in labor, premature preterm rupture of membrane G2P1 (1001), previous cesarean section due to oligohyrdramnios; pregestational diabetes mellitus type II; chronic hypertensive vascular disease; rule out urinary tract infection

Diagnostics * Speculum Exam * Nitrazine test for the ruptured

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