Case #1: General Data

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#27 GHANAWAT ANIKET LAXMAN

IMD-19/B
DR. CECILE MELISSE DERECHO

CASE #1

GENERAL DATA

Name: BC Age: 22yr old


Religion:
Address: Davao city
Date/Time of admission: May 6, 2021; 6pm
Source of information: Patient Reliability: 95%

CHIEF COMPLAINT: Labor pain and bloody vaginal discharge.

HPI

6 hours prior to admission, patient started experiencing labor pain accompanied


with mucoid bloody vaginal discharge. Uterine contractions in every 10 minutes.
3 hours PTA, uterine contractions noticed were in every 3-5 mins. Labor pain
increased in severity hence, admission.

OB AND GYNE HISTORY

 G2P0 (0010)
 LMP – Aug 1, 2020
 AOG – 39^5/7 weeks
 EDD – May 8, 2021 (1st day of last LMP + 7 Days – 3 months + 1 year)
CASE #2

GENERAL DATA

Name: TC Age: 29yr old


Religion:
Address: Davao city
Date/Time of admission: May 6, 2021; 4pm
Source of information: Patient Reliability: 95%

CHIEF COMPLAINT: Bloody vaginal discharge.

HPI

5 hours prior to admission, patient started experiencing labor pain.


2 hours PTA, labor pain associated with blood-streaked mucoid vaginal discharge.
Hence, consultation and admission.

OB AND GYNE HISTORY

 G3P2 (2002)
 LMP – Sep 1, 2020
 AOG – 35^2/7 weeks
 EDD – June 8, 2021 (1st day of last LMP + 7 Days – 3 months + 1 year)

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