Name of Student: Dinakaran Deva Surya Roll no: 46

Date: JULY 20,2022

Batch/Sec: IMD21 A
PRECEPTOR: DR. DELA VICTORIA

PATIENT’S IDENTIFYING DATA:

Name:xxx
Age: 35 year old
Gender: Female
Civil Status:
Address: Bajada, Davao City, Occupation:
Religion: Roman Catholic. Source of History: Patient. Reliability: 90%

CHIEF COMPLAINT:
Vaginal Bleeding
HISTORY OF PRESENT ILLNESS (HPI):
• 2 hours Prior to admission, while patient was riding a bus going to Digos City when she
noted bright red vaginal bleeding.She also had her uterus contracting every 2- 3 minutes, the
character of the contractions were strong, associated with generalized abdominal pain.No
consultation was done until the patient reached her destination.
• 30 minutes Prior to admission , the patient experienced severe abdominal pain along with
continuous uterine contraction , with no rest in between. moderate vaginal bleeding,
becoming blood clots were notes and hence, the patient was brought to the ER for further
evaluation, and subsequently admitted

PAST MEDICAL HISTORY:

• Patient had Gestational Hypertension during her first pregnancy. • Had Undergone
Cesarean Section during her 2nd Pregnancy.

OBSTETRIC AND GYNECOLOGIC HISTORY:

PRENATAL HISTORY:
• First Trimester:BP=140/90mmHg. Aspirin 150 mg/day. Maintained on antihypertensive for
6 weeks. Non-hypertensive after 6 weeks. She was prescribed Folic Acid 5 mg 1 tablet daily.
VDRL (Non- Reactive); She was also prescribed Ferrous Sulfate once daily and Vitamin C to
be taken with Ferrous.
Transvaginal scan shows single live fetus at 10 weeks’ gestation, developing placenta;
active fetal movements; good cardiac activity(FHT=155 bpm)
UA (normal); HbsAg (Reactive). HIV= non-Reactive

• Second trimester: At 20 weeks AOG, BP = 138/95 mmHg;

Transabdominal scan reveals a single live male fetus 20 weeks by fetal biometry, cephalic
presentation, with good cardiac activity, placenta located posteriorly with the inferior edge
1.5 cm away from the
internal os; Normohydramnios. Laboratory tests included CBC (hgb=120 d/L).Preeclampsia
panel was normal.
• Third trimester: 30 weeks’ gestation BP 150/100. Prescribed Methyldopa 250 mg 3x/day.
She was advised to come back to the OPD after 2 weeks. Antihypertensive taken for 2
weeks. At 32 weeks’ gestation, patient stopped her antihypertensive medications due to
financial constraints. up. No consultation since then.
• OB CODE : G3P2(2002) • LMP : Dec 21,2021
• AOG: 30 wks1days

G1-NSVD(2008)-GESTATIONAL HYPERTENSION

G2-CS(2016)-PRETERM 32WEEKS FAILURE TO COME FOR PRENATAL CHECK UP

FAMILY HISTORY
• Father is hypertensive and maintained on antihypertensive medications.
• Mother has diabetes and maintained on Metformin 500 mg 1 tablet 2x/day. • A younger
sibling also has hypertension.
• An older brother died (2018) of CVA at 38-years-old.