Ob Case Write Up
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 completed her monthly check-ups with her attending physician. Patient had no exposure to any illness, radiation, or teratogens. In the second trimester, at the 23rd week of pregnancy, patient noted watery discharge, fluid in consistency amounting to 1 teaspoon staining her underwear. There was no blood or mucoid noted at the time and patient did not experience any uterine contraction. There was good fetal tone. Patient then sought consult and was worked up. It was found out that patient had premature preterm rupture of membrane. No medications were given. Instead patient was advised to come back on her 28th week of pregnancy for follow up. Prior to the present complaint, pregnancy history was unremarkable.
Past Medical History The patient was diagnosed to have diabetes mellitus type II last 2006 and is currently taking metformin for maintenance. She was also diagnosed to be hypertensive last 2007. Other than the mentioned illnesses, patient does not have any history of thyroid disease, cardiac disease, nor cancer. Patient also does not have any allergies to food or medications.
Ob/Gyn History The patient is a multigravid with no past obstetrical complaints, hospitalizations, or surgeries. Patient had her menarche was at the
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 completed her monthly check-ups with her attending physician. Patient had no exposure to any illness, radiation, or teratogens. In the second trimester, at the 23rd week of pregnancy, patient noted watery discharge, fluid in consistency amounting to 1 teaspoon staining her underwear. There was no blood or mucoid noted at the time and patient did not experience any uterine contraction. There was good fetal tone. Patient then sought consult and was worked up. It was found out that patient had premature preterm rupture of membrane. No medications were given. Instead patient was advised to come back on her 28th week of pregnancy for follow up. Prior to the present complaint, pregnancy history was unremarkable.
Past Medical History The patient was diagnosed to have diabetes mellitus type II last 2006 and is currently taking metformin for maintenance. She was also diagnosed to be hypertensive last 2007. Other than the mentioned illnesses, patient does not have any history of thyroid disease, cardiac disease, nor cancer. Patient also does not have any allergies to food or medications.
Ob/Gyn History The patient is a multigravid with no past obstetrical complaints, hospitalizations, or surgeries. Patient had her menarche was at the