Ob Admission Conference June 3 4

ADMISSION
CONFERERENCE
Hospitalist: Dr. Umipig
Resident: Dr. Gamboa-Chua
PGI: Dr. Angeles/Geluz/Martin
JI: Cruz/Munoz
Pathologic 1 Resolved 1
OBSTETRIC Non-
1 Unresolved 1
pathologic
Resolved 0
GYNECOLOGIC 2
Unresolved 2
TOTAL 4
Floor New Old
3rd MT 0 2
5th MB 2 1
WARD 7th MT 1 1
CENSUS 8th MT 1 3
9th MT 0 1
Total 4 8
Total 12
OBSTETRICS - UNRESOLVED
PLAN/
# AGE ADMITTING DIAGNOSIS FINAL DIAGNOSIS
MANAGEMENT
G1p0 Pregnancy Uterine 34
2/7 weeks Age of Gestation by
EUTZ, Cephalic in Threatened
Preterm Labor,
27 Hyperthyroidism, Overt Expectant
1
LK Diabetes Mellitus Type II – Management
Insulin Requiring,
Preeclampsia without severe
Features, Upper Respiratory
Tract Infection
OBSTETRICS - RESOLVED
ADMITTING PLAN/
# AGE FINAL DIAGNOSIS
DIAGNOSIS MANAGEMENT
G2P2 (2002) Pregnancy
G2P1(1001) Normal Uterine Term Cephalic
Pregnancy Spontaneous Delivered via Normal
Vaginal Spontaneous Vaginal
26 Uterine 38 4/7
1 Delivery with Delivery to a live baby
ML weeks Age of Right boy AS 8,9 BW 3.32 kg,
Gestation Mediolateral BL 54 cm, NMR: 38
Cephalic In Labor Episiotomy weeks, AGA, single
nuchal cord coil
GYNE - UNRESOLVED
PLAN/ FINAL
# AGE ADMITTING DIAGNOSIS
MANAGEMENT DIAGNOSIS
G0 Abnormal Uterine
28 Bleeding secondary to Medical
CK Endometrial Hyperplasia; Management
PCOS
G4P4 (4004) T/C URINARY
77 TRACT INFECTION, ACUTE
Medical
EG CYSTITS VS ACUTE
Management
PYELONEPHRITIS
GENERAL DATA
• L.K.
• 27y/o
• G1P0 34 2/7 weeks AOG by EUTZ
• Single
• Roman Catholic
• Capas, Tarlac
CHIEF COMPLAINT
For NST
HISTORY OF PRESENT ILLNESS
5 days PTA
• Patient sought regular prenatal consult.
• Noted mild uterine contractions occurring in a 20-
min interval, advised NST.
• No vaginal discharge, No hypogastric pain, (+)
Good Fetal Movement
• No other problems/illnesses detected.
3 days PTA,
• Patient had sore throat with non productive,
nondistressing cough.
• No fever, dysuria noted
Few Hours PTA,

• Patient returned for NST.
• non productive, nondistressing cough persisted.
• No vaginal discharge, No hypogastric pain, (+)
Good Fetal Movement
G1P0
Place of
Child
Duration Manner of
Confinement Compli- Present
of Delivery Assisted by: Condition
No. Year cations
Delivery Weight Conditi
at Birth
on
G1 Present pregnancy
LMP: 10/2018 AOG: 34 2/7 weeks by EUTZ

EDC: 7/13/2019
OB History
Prenatal Check-Up
• Adequate
• Since 7 weeks AOG – Early UTZ Done
• Followed Schedule provided by OB
• Tested for infections (NEGATIVE) – RPR, Hepa B,
HIV
• No other illnesses Detected.
GYNE History
M 11
I 30 days
D 5 days
A 5 pads/day mod soaked
S (-) dysmenorrhea
GYN
1st sexual contact 21y/o

# sexual partner 2
PCB none
Dyspareunia none
Contraceptives none
STI none
Pap smear none
PAST MEDICAL HISTORY
(+) Type 2 Diabetes Mellitus (Since July 2018)

- Insulin Humulin (Insujet) 70/30
-40 Units AM, 20 units PM (Premeals)
(+) Hyperthyroidism (July 2018)
-Maintained on Methimazole 2 mg OD (PTU during
1st Trimester)
-Medications were stopped 3 weeks PTA
(-) Hypertension
(-) Bronchial asthma
(-) STD/UTI
(-) Thyroid disease
(-) Allergies to food and drugs
(-) Previous surgeries
(-) History of anovulation
(-) Blood dyscrasias
FAMILY MEDICAL HISTORY
(+) Diabetes Mellitus – Maternal Side

(-) Hypertension
(-) Diabetes mellitus
(-) Thyroid disease
(-) Cancer
(-) CAD
(-) CVD
PERSONAL AND SOCIAL HISTORY
VITAL SIGNS
BP: 150/100
PR: 117
RR: 20
T: 36.1
Height: 5’5”
Current Weight: 75 kg
Pre-Pregnancy Weight: 63 kg
BMI: 23.16
Admitting
Medical History Physical Exam Plan
Diagnosis
PHYSICAL EXAMINATION
Skin
No jaundice, pallor, or cyanosis; Capillary refill time is <2 seconds. No Edema.
HEENT
Exophthalmia. Anicteric sclera, pink palpebral conjunctiva
Neck
With palpable bilateral anterior neck mass which moves with deglutition, no
cervical lymphadenopathies
Lungs
Symmetrical chest expansion, no retractions, clear breath sounds
Heart
Adynamic precordium, no heaves or thrills, tachycardic, normal rhythm, no
murmur
Admitting
Diagnosis
Abdomen
Globular, no scars, NABS, non- LM1 – Soft, Irregular Mass
tender
FH: 29 LM2 – Fetal Back at the Right
FHT: 153 LM3 – Round Ballotable
EFW: 2480 LM4- n/a
External
Grossly normal external genitalia, hair evenly distributed, no lesions or
mass
Speculum Exam
Not done
Internal Exam
Cervix Closed
 Cephalic, Singleton, 171 bpm
 AFI: 4.5 cm
Latest  Placenta: Anterior, High Lying Grade II
UTZ  EFW: 2156 grams
May 16, 2019
 Average Ultrasonic Age: 33 2/7 Weeks
31 5/7 AOG
 BPD: 8.1 cm – 32 5/7 weeks AOG
 OFD: 10.6 cm – 33 4/7 weeks AOG
 HC: 30.2 cm - 33 4/7 weeks AOG
UTZ
 AC: 29.0 cm - 33 weeks AOG
 FL: 6.5 cm- 33 5/7 weeks AOG
Urinalysis: (+3) Sugar, (+1)
Albumin
CBC:Hgb: 144
LABS
Hct 0.44
WBC: 15.4
Plt Ct: 221
Admitting Diagnosis
 Baseline FHR: 140-145, Class I, Moderate Variability,
with accelerations and no decelerations. Mild to
Moderate Contractions occurring every 5 to 10 minutes.
 4:00 PM – Cervix Closed
 4:10 PM – Given Nifedipine 30 mg/tab PO
 7:45 PM – HGT: 100
 8:15 PM – IVF PLRS x 8 hrs
 9:07 PM – Hydralazine 5mg IV
Course in the  9:18 PM – Propranolol 20 mg PO
Labor Room  9:45 PM – Propranolol 20 mg PO
 9:54 PM – Nubain 5 mg IV
 11:10 PM – Heragest Vaginal Suppository
 1:40 AM – Nubain 5 mg Promethazine 12.5
 6:43 AM – Methyldopa 250 mg
LATEST CTG – As of 5:30 to 6:00AM
 Baseline FHR: 140-145, Class I, Minimal Variability, with

no accelerations and decelerations. Moderate to Strong
Contractions occurring every 3 to 5 minutes.
GENERAL DATA
• M.L.
• 26y/o
• G2P1 (1001) 38 4/7 Weeks AOG
• Single
• Roman Catholic
• Bamban, Tarlac
CHIEF COMPLAINT
Labor pains
2 hours PTA
• Hypogastric pain radiating to the lumbosacral
area, 7/10 pain scale with perceived uterine
contractions of 1 contraction in 10 minutes lasting
for at least 1 minute. No Discharge. (+) GFM
• Prompt Current Consult
G2P1 (1001)
Place of
Child
Duration Manner of
Confinement Compli- Present
of Delivery Assisted by: Condition
No. Year cations
Delivery Weight Conditi
at Birth
on
Hospital
G1 2016 FTBB NSD n/a n/a n/a Alive
OB
G2 Present pregnancy
LMP: 9/06/2018 AOG: 38 5/7 weeks

EDC: 6/13/2019
OB History
Prenatal Check-Up
• Adequate
• Since 2 months
• Followed Schedule provided by OB
• No illnesses or problems noted
GYNE History
M 13
I 28 to 32 days
D 3 days
A 4 pads/day mod soaked
S (+) dysmenorrhea
GYN
1st sexual contact 17y/o

# sexual partner 1
PCB none
Dyspareunia none
Contraceptives none
STI none
Pap smear none
PAST MEDICAL HISTORY
(-) Diabetes Mellitus

(-) Hypertension
(-) STD/UTI
(-) Thyroid disease
(-) Allergies to food and drugs
(-) Previous surgeries
(-) History of anovulation
(-) Blood dyscrasias
FAMILY MEDICAL HISTORY
(+) Bronchial Asthma - Brother

(-) Hypertension
(-) Diabetes mellitus
(-) Thyroid disease
(-) Cancer
(-) CAD
(-) CVD
PERSONAL AND SOCIAL HISTORY
VITAL SIGNS
BP: 120/80
PR: 67
RR: 16
T: 36.7
Height: 5’6”
Current Weight: 54 kg
Pre-Pregnancy Weight: 48 kg
BMI: 17.20 - UNDERWEIGHT
Admitting
Diagnosis
Skin
No jaundice, pallor, or cyanosis; Capillary refill time is <2 seconds.
HEENT
Anicteric sclera, pink palpebral conjunctiva
Neck
No neck masses, no cervical lymphadenopathies
Lungs
Symmetrical chest expansion, no retractions, clear breath sounds
Heart
no murmurs, regular rate and rhythm
Admitting
Diagnosis
Abdomen
Globular, no scars, NABS, LM1 – Soft, Irregular Mass
nontender
FH: 34 LM2 – Fetal Back at the Right
FHT: 153 LM3 – Engaged
EFW: 3410 LM4-
External
Grossly normal external genitalia, hair evenly distributed, no lesions or
mass
Speculum Exam
Not done
Internal Exam
4 cm Dilated, 50% Effaced, Soft, Posterior St -3, (+) BOW, Cephalic
BISHOP’s SCORE: 5
Admitting Diagnosis
 Baseline FHR: 130-135, Class I, Minimal to Moderate
Variability, with no accelerations and decelerations.
Moderate to Strong Contractions occurring every 5 to
7.5 minutes.
Cervix 4cm 50%
effaced posterior soft
st -3
(+) BOW cephalic
D5LRS 1L + Oxytocin
10 u x 10 gtts/min
10 -5
-4
Cervical Dilatation
8 -3
Fetal Station
-2
6 -1
0
4 +1
+2
2 +3
+4
0 +5
1 2 3 4 5 6 7 8 9
FD 200 cc D5 LRS, O2
at 5LPM
HNBB 1 amp/ SIVP Q4

FINAL Diagnosis
1
Medical History Physical Exam Admitting Diagnosis Plan
Chief Personal Social

General Data HPI OBGYN PM Hx FMHX
Complaint Hx
GENERAL DATA
• Px KJ
• 28 years old
• Single
• Roman Catholic

Complaint Hx
Chief complaint
Prolonged Menses

Complaint Hx
• 1.5 months PTC (April 26,2019) px complained of

History of present
prolonged illness
menses. Px noted it to be continuous
bleeding with presence of blood clots. She is consuming
5 pads fully soaked per day accompanied by hypogastric
pain with a pain scale of 5/10 that radiates to the back.
No other symptoms noted.
• 1 week PTC patient sought consult and was given
progesterone and ultrasound was done revealing
thickened endometrium.

Complaint Hx
History of present illness

• 5 days PTC, Patient noted no relief of symptoms from
progesterone and bleeding persisted.
• Few hours PTC, patient complained of dizziness and
increasing hypogastric pain with a pain scale score of
7/10 , hence was subsequently admitted.
ULTRASOUND REPORT
TRANSVAGINAL:
The uterus is anteverted with smooth contour and homogenous echopattern
measuring 6.9x4.4x3.6 cm. The cervix measures 2.6x2.9x3.1 cm with
homogenous stroma and distinct endocervical canal
The endometrium is hyperechoic measuring 0.9cm with cystic spaces within.
The subendometrial halo is intact
The right ovary measures 3.2x2.9x2.1 cm. The left ovary measures
2.6x2.0x2.0 cm. Both ovaries have multiple peripherally located follicles (>12
per scan field) measuring less than 1cm in diameter.
There are no adnexal masses seen. There is no free fluid in the cul-de-sac.
IMPRESSION:
NORMAL SIZED ANTEVERTED UTERUS. THICKENED ENDOMETRIUM,
CONSIDER ENDOMETRIAL PATHOLOGY. POLYCYSTIC OVARIES

Complaint Hx
G0P0
Duration Place of Child

Manner of
No. Year of
delivery
confinement; Complication Condition at Present
delivery Assisted by: Weight
birth condition
G0
LMP: 04/16/19

Complaint Hx
GYNE History
LMP: 1/15/18
M 14 years old
I 20 to 28 days
D 3 to 7 days
A 3pads per day mod soaked
S (-) dysmenorrhea

Complaint Hx
GYNE History
1st sexual contact 16 y/o
# sexual partner 5
LSC May 2019
PCB (+)
Dyspareunia none
Contraceptives none
Pap smear none


Complaint Hx
Past medical history

• (-) UTI • (-) History of obesity
• (-) Hypertension • (-) History of anovulation
• (-) Diabetes mellitus • (-) Blood dyscrasias
• (-) Bronchial asthma
• (-) STD/UTI
• (-) Thyroid disease
• (-) Allergies to food and drugs
• (-) Previous surgeries

Complaint Hx
Family medical history

• (+) Hypertension - B
• (+) Diabetes mellitus - B
• (+) Bronchial asthma - B
• (+) Cervical Cancer - M
• (-) CAD
• (-) CVD

Complaint Hx
Personal & Social history
× Smoker
× Alcoholic beverage
Angeles City
College graduate
Call center agent

Vital Signs
• BP: 120/90 mmHg

• HR: 94 bpm
• RR: 18 cpm
• Temp: 37.7 °C
• Current weight: 65 kg
• Height: 160cm
• BMI: 25.39 (Overweight)
Physical exam
No jaundice, pallor, or cyanosis; normal skin turgor with no erythema, rashes or ulcerations.
Skin Nail beds are normal, no clubbing or cyanosis. Capillary refill time is <2 seconds
HEENT Anicteric sclera, pink palpebral conjunctiva
Neck No neck masses, no engorged vein, no cervical lymphadenopathies
Lungs Symmetrical chest expansion, no retractions, clear breath sounds
Heart Adynamic precordium, no murmurs, regular rate and rhythm

Physical Exam
Abdomen
Flabby, no scarsor any lesions. LM1 – N/A
Mild tenderness upon LM2 – N/A
palpation on hypogastric area, LM3 – N/A
normoactive BS LM4 – N/A
External
Grossly normal external genitalia, hair evenly distributed, no lesions or mass
Speculum Exam Cervix pink and smooth, no lesions and no mass. Moderate bloody discharge
Internal Exam Uterus not enlarged, no mass palpated.

Medical History Physical exam Admitting Diagnosis Plan
Admitting diagnosis
G0 Abnormal Uterine Bleeding secondary to Endometrial

Hyperplasia; PCOS
Plan
Medical Management
Medical History Physical exam Admitting Diagnosis Plan Final diagnosis
Final diagnosis
……
2

Complaint Hx
GENERAL DATA
• Px EG
• 77 years old
• Married
• Roman Catholic

Complaint Hx
Chief complaint
Fever/ Difficulty urinating


Complaint Hx
• 3 days PTA, patient experienced intermittent fever

History
(Tmax of
of present illness
39 degrees C) with accompnying difficulty of
urinating. There was no pain noted in urinating. There is
minimal hypogastric pain. No other symptoms noted.
OB SCORE
G4P4 (4004)
G1- 1965, GIRL, FT, NSD, @HOME
G2 – 1967, GIRL, FT, NSD, @HOSPITAL
G3 – 1970, BOY, FT, NSD, @HOSPITAL
G4 – 1977, BOY, FT, NSD @HOSPITAL

Complaint Hx
GYNE History
LMP: UNRECALLED
M 16 years old
I 28 to 30 days
D 3 to 4 days
A 3-5 pads per day, FS
S (-) dysmenorrhea

Complaint Hx
GYNE History
1st sexual contact 22 y/o
# sexual partner 1
LSC UNRECALLED
PCB none)
Dyspareunia none
Contraceptives none
Pap smear none


Complaint Hx
Past medical history

• (-) UTI • (-) History of obesity
• (-) Hypertension • (-) History of anovulation
• (-) Diabetes mellitus • (-) Blood dyscrasias
• (-) STD/UTI
• (-) Allergies to food and drugs
• (-) Previous surgeries

Complaint Hx
Family medical history

• (+) Hypertension - M
• (-) Diabetes mellitus
• (-) Cervical Cancer
• (-) CAD
• (-) CVD

Complaint Hx
Personal & Social history
× Smoker
× Alcoholic beverage
BULACAN
College graduate
N/A
Vital Signs
• BP: 120/90 mmHg

• HR: 62 bpm
• RR: 20 cpm
• Temp: 36.6 °C
• Current weight: 40 kg
Physical exam
No jaundice, pallor, or cyanosis; normal skin turgor with no erythema, rashes or ulcerations.
Skin Nail beds are normal, no clubbing or cyanosis. Capillary refill time is <2 seconds
HEENT Anicteric sclera, pink palpebral conjunctiva
Neck No neck masses, no engorged vein, no cervical lymphadenopathies
Lungs Symmetrical chest expansion, no retractions, clear breath sounds
Heart Adynamic precordium, no murmurs, regular rate and rhythm

Physical Exam
Abdomen
Flabby, no scars, or any lesions. No LM1 – N/A
tenderness upon palpation on LM2 – N/A
hypogastric area, + mild hypogastric
pain. normoactive BS LM3 – N/A
*KIDNEY PUNCH - UNREMARKABLE LM4 – N/A
External
Grossly normal external genitalia, hair evenly distributed, no lesions or mass
Speculum Exam NOT DONE
Internal Exam NOT DONE

LAB RESULTS
HEMOGLOBIN – 115
HEMATORIT – 0.33
RED BLOOD CELL COUNT – 3.75
MCV – 88.8
MCH – 30.7
MCHC – 34.5
WHITE BLOOD CELL COUNT – 14.24
NEUTROPHILS – 0.84
LYMPHOCYTES 0.05
PLATELET COUNT – 0.11
Admitting diagnosis
G4P4 (4004) T/C URINARY TRACT INFECTION, ACUTE

CYSTITS VS ACUTE PYELONEPHRITIS

Ob Admission Conference June 3 4

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ob Admission Conference June 3 4

Uploaded by

Copyright:

Available Formats

ADMISSION

Few Hours PTA,

LMP: 10/2018 AOG: 34 2/7 weeks by EUTZ

1st sexual contact 21y/o

(+) Type 2 Diabetes Mellitus (Since July 2018)

(+) Diabetes Mellitus – Maternal Side

 Baseline FHR: 140-145, Class I, Minimal Variability, with

LMP: 9/06/2018 AOG: 38 5/7 weeks

1st sexual contact 17y/o

(-) Diabetes Mellitus

(+) Bronchial Asthma - Brother

HNBB 1 amp/ SIVP Q4

Chief Personal Social

Chief Personal Social

Chief Personal Social

• 1.5 months PTC (April 26,2019) px complained of

Chief Personal Social

History of present illness

Chief Personal Social

Duration Place of Child

Chief Personal Social

Chief Personal Social

LSC May 2019

Pap smear none

Chief Personal Social

Past medical history

Chief Personal Social

Family medical history

Chief Personal Social

Personal & Social history

Call center agent

• BP: 120/90 mmHg

HEENT Anicteric sclera, pink palpebral conjunctiva

Neck No neck masses, no engorged vein, no cervical lymphadenopathies

Lungs Symmetrical chest expansion, no retractions, clear breath sounds

Heart Adynamic precordium, no murmurs, regular rate and rhythm

Internal Exam Uterus not enlarged, no mass palpated.

G0 Abnormal Uterine Bleeding secondary to Endometrial

Chief Personal Social

Chief Personal Social

Fever/ Difficulty urinating

Chief Personal Social

• 3 days PTA, patient experienced intermittent fever

Chief Personal Social

Chief Personal Social

Pap smear none

Chief Personal Social

Past medical history

Chief Personal Social

Family medical history

Chief Personal Social

Personal & Social history

• BP: 120/90 mmHg

HEENT Anicteric sclera, pink palpebral conjunctiva

Neck No neck masses, no engorged vein, no cervical lymphadenopathies

Lungs Symmetrical chest expansion, no retractions, clear breath sounds

Heart Adynamic precordium, no murmurs, regular rate and rhythm

Speculum Exam NOT DONE

Internal Exam NOT DONE

G4P4 (4004) T/C URINARY TRACT INFECTION, ACUTE

You might also like