Kimberly Ann A.

Leorag Block 7 Level 3

Informant: Patient Date: August 12, 2020
% Reliability: 95% Time: 4:00 PM

General Data: A case of A.A., 25 years old, Filipino, female, G1P0, single, Born Again Christian,
a call center agent from Lahug, Cebu City went to the ER of University of Cebu Medical Center
for the first time on August 12, 2020 at 4:00 PM due to labor pain.

Chief Complaint: Labor Pain

Past Medical History:

Patient claims to have no childhood illnesses such as measles, chickenpox, mumps, and
smallpox. No food and drug allergies. She also claims to have complete immunization taken from
the barangay health center although said immunizations were unrecalled. Patient also claims to
have no comorbidities such as hypertension, diabetes mellitus, asthma, cancer, kidney and heart
disease, liver disease, and HIV. No prior history of hospitalizations, surgical operations,
injuries/accidents as well as psychiatric consultations/treatments.

Family Medical History:

Father is 55 years old, alive, with hypertension and is on medication with Losartan, compliant.
Mother is 50 years old, alive, with no known diseases. There is a heredofamilial predilection of
hypertension in the father side and no known heredofamilial disease in the mother side. They are
a total of 5 in the family, with 2 younger siblings ages 21 and 22 with no known health problems.
There is no history of twinning, difficult deliveries, and congenital anomalies in the family.

Personal and Social History:

Patient work as a call center agent. Her partner is temporarily unemployed, a nonsmoker and a
non-alcoholic beverage drinker. She is currently living at the same house with her partner for 3
years with her parents in one compound at Lahug. Patient is a nonsmoker, non-alcoholic
beverage drinker and denies use of illicit drugs. She claims of walking for 5-10 min/day as her
mode of exercise. She sleeps at least 8 hours a day, with no difficulty. Patient eat regular meals
a day consisting mostly of vegetables. She usually drinks at least 3 liters of water per day. She
urinates most of the time since she drinks a lot of water and defecates at least once a day. No
known food and drug allergies.

Obstetric and Gyne History:

Menstrual History:
Menarche was at age 14 years old with regular menstrual cycles of 28 days, lasting for 4
days with moderate flow consuming 3 fully soaked pads per day on average. No noted
skipping of periods. Dysmenorrhea was felt with mild discomfort. No pain during coitus
and no spotting or bleeding occurred in between menses. LMP is November 11 2019.

Contraceptive History: No history of contraceptive use as claimed.

 Sexual History:
Coitarche at 22 years old with only one partner and was sexually active prior to pregnancy.
Good sexual satisfaction, no postcoital bleeding and discharge, no sexual dysfunction.

Obstetric History:
Patient is G1P0, 39 2/7 weeks AOG by the last menstrual period. Estimated date of
confinement is August 18, 2020.

Prenatal History:
Patient had her first prenatal check-up by a midwife at her local barangay health center at
approximately 11 weeks AOG with EDC on August 18, 2020 by LMP. She only had one
subsequent prenatal check-up in the same barangay health center on instead of a regular
monthly check-up due to the enhanced community quarantine. CBC and urinalysis were
taken on August 9, 2020 with unremarkable results. No other labs were taken. Vaccination
was not done. No illness acquired during pregnancy. She was given Iron, 1 tablet, once
daily with good compliance and Calcium, 2 tablets per day with good compliance. No other
medications were taken. She felt a movement in her abdomen last April 2020, exact day
unrecalled. She gained 15 kg during her pregnancy period. She has a normal usual blood
pressure reading of 100/60 mmHg.

History of Present Illness:

8 hours prior to arrival at the ER, patient had onset of mild to moderate contractions every 10
minutes lasting for 15 second with a pain score of 2/10. Pain was localized in the hypogastric
region. There were no associated watery or bloody discharge or symptoms like fever, dizziness,
headache, vomiting, and blurring of vision. Patient tried walking inside the house to relieve
symptoms but pain still persisted.

4 hours prior to arrival at the ER, the patient had more frequent labor pains lasting for 15 seconds
every 2 minutes. There were still no associated watery or bloody discharge or any other
symptoms.

1 hour prior to arrival at the ER, the patient's abdominal pain started to radiate to the lower back.
This time, a bloody discharge was which was dark red in color and an amount approximately that
of a fully soaked panty liner. This prompted the patient to go to the ER of the hospital.

Physical Examination:
General Survey: Examined a conscious, alert, and cooperative patient, not in respiratory distress
with the following vital signs:
BP: 100/70 mmHg (left arm, supine) Pain score: 2/10
HR: 85 beats/min O2 Saturation: 99%
RR: 22 cycles/min Prepregnancy weight: 50kg
Temperature: 36.5°C (ears) Pregnancy weight: 65kg
Height: 5’2” BMI: 26.2 kg/m2(normal)

Skin: warm, good turgor, no active lesions, no rashes, no jaundice

HEENT: Skin: warm, good turgor, no active lesions, no rashes, no jaundice, no discoloration
 Head: Normocephalic, symmetrical, fine black hair evenly distributed throughout the head,
no flakes, no scales, no lumps seen on the scalp

Eyes: Well-aligned with no deviations nor protrusions, eyebrows evenly distributed with
no flakes, equal palpebral fissures, eyelashes directed outwards, pinkish palpebral
conjunctiva, anicteric sclerae, cornea transparent, pupils 4mm in both eyes equally
reactive to light, direct and consensual, full range extraocular muscle movements by
Finger Following test, good convergence, able to read newsprint at 2 feet distance
bilaterally, no visual defects by confrontation test

Ears: No deformities, no tenderness, no discharges, able to hear whispered voice test at

2 feet distance

Nose and Paranasal Sinuses: No deformities, no alar flaring, nasal septum midline, no
discharges, no tenderness over the paranasal sinuses, able to transilluminate

Mouth and pharynx: Lips red and moist, buccal mucosa pink, no lesions, complete set of
teeth, no dental carries, tongue midline on protrusion, no lesions, uvula midline, no
tonsillopharyngeal congestion

Neck: Cervical lymph nodes not palpable, trachea midline, thyroid gland not palpable, neck veins
not engorged, no carotid bruits, no thrills

Chest and Lungs: Anterior and Posterior chest: equal chest expansion, no deformities, no
intercostal retractions; no tenderness, equal tactile fremitus, resonance in both lung fields;
vesicular breath sounds in both lung fields, no adventitious breath sounds, no crackles, no
wheezes, no rhonchi.

Breasts: skin is fair, symmetrical, no rashes, no dimpling, no flattening, no tenderness, no

palpable nodules, nipples everted, no discharges

Cardiovascular: Examinations to get the PMI, cardiac area of dullness , JVP were not done; S1
and S2 distinct, no murmurs, regular rhythm

Abdomen: Gravid, (+) linea nigra, (+) striae gravidarum, (-) cesarean/surgical scars, fundal height
32 cm, LM1 breech, LM2 fetal back at left maternal side and fetal extremities on right maternal
side, LM3 cephalic, LM4 divergent examining tweezers , FHR 150 bpm, moderate to strong
contractions occurring regularly every 3 minutes for 40 seconds.

GUT: no lesions, internal examination showed 4cm dilation, 80% effacement, fetal station-3,
intact, presenting part is cephalic presentation

Rectal: Procedure not done.

Peripheral vascular system: strong radial, brachial, femoral, popliteal, posterior tibial and dorsalis
pedis pulses, good return flush on Allen’s test, has bilateral edema with a grade of 2, no
varicosities, no limitation in movement
Muskuloskeletal: No swelling, no deformities, full range of motion in all joints of the upper and
lower extremities.
Neurologic Exam: Coherent, oriented to time, place, and person
Cranial Nerves
CN 2, 3: pupils 3mm equally brisk reactive to light and accommodation
CN 3,4,5: full extraocular muscle movement
CN 5,7: positive corneal reflex, each eye
CN 7: no facial asymmetry
CN 8: able to hear spoken voice test, each ear, Rinne and Weber’s test not done
CN 9, 10: positive gag reflex
CN 11: able to shrug shoulders and turn head against resistance
CN 12: tongue midline
Cerebellar: Intact Finger-to-nose and Heel-to-shin-test
Sensory: sensation intact to pain, temperature and light touch
Motor: no atrophy or involuntary movements, and good muscle tone with no limitations
Reflexes: