PATIENT m.p.

,
38-years old
GRAND ROUNDS
General data:
M.P., a 38-year-old G3P1 (1021),
married, Filipino, Roman
Catholic and a DepEd Teacher,
from Danao, Cebu was
admitted for the first time at
UCMed last November 10, 2022
at 11pm due to vaginal
bleeding.
 MENSTRUAL HISTORY:
● Menarche was at 12 years old.

● Subsequent menses are regular which occurs every month with 7 days per cycle.

○ In the 1st five days, the patient consumes 3 fully soaked sanitary pads.

○ On the subsequent days, the patient consumes 2 mildly soak sanitary pads.

● Monthly menstruation is described to be bright reddish brown as normally expected.

● She does not experience dysmenorrhea, breast tenderness and symptoms of

premenstrual syndrome such as increased appetite and mood swings.

● LMP: May 7, 2022

● PMP: April 12, 2022

 OBSTETRIC HISTORY:

● The patient’s OB score is G3P1 (1021)

● Previous Pregnancy:

○ G1 : 2003, 37 weeks AOG, NSVD, female, 2.6kgs from CVGH

○ G2 : 2015, 7 weeks AOG, Spontaneous abortion due to blighted ovum

○ G3 : October 1, 2021, 17 weeks AOG, Intrauterine fetal demise

 CONTRACEPTIVE HISTORY:

● Patient and partner does not use any contraceptive method.

 SEXUAL HISTORY:
● Coitarche at 19 years old.

● The patient has had 3 sexual partners since.

● Her sexual partners are males and is currently sexually active with current live-in partner
as the sole sexual partner.

○ Frequency of intercourse at 3 times per week.

● Patient claims to be satisfied with her experiences.

● No dyspareunia, postcoital bleeding, or any sexual dysfunction.

● No history of sexually transmitted infections.

 PAST MEDICAL HISTORY:
● Patient has unrecalled primary immunization status

● Childhood illnesses include mumps, measles, and chickenpox - uncomplicated, unrecalled

medications, was relieved.

● In 2014, the patient underwent Pelvic Laparoscopy Salpingo-oophorectomy of Left ovary

due to Dermoid Cyst at CDUH

● In 2021, patient received two doses of COVID-19 vaccination (Sinovac)

● She does not have hypertension, diabetes mellitus, asthma, thyroid diseases, or
cardiovascular diseases

● No known food and drug allergies.

 PERSONAL SOCIAL HISTORY:
● The patient is a college graduate with a degree in Education

● She has been working as a teacher for 12 years now and works 8 hours per day and 5
days per week.

● She sleeps at an average of 8 hours per day.

● Main source of stress is her job.

● Usual diet consists mainly of home cooked food

○ She also eats fatty food, biscuits, rice, and some fish.

○ She drinks about 500mL of water per day.

● She is non-alcoholic, non-smoker, and has no history of illicit drug use

 FAMILY HISTORY:

● Mother is 79 years old, diagnosed with diabetes mellitus and hypertension

○ Heredofamilial diseases: Diabetes mellitus, Breast carcinoma, and Myoma

● Father is 80 years old, diagnosed with hypertension

○ Heredofamilial diseases: Hypertension

● Patient ranks fifth among 7 siblings

● One of her sister was diagnosed with myoma and has a history of complicated pregnancy
(nonreassuring fetal heart pattern)
 HYpogastric pain and
heavy vaginal bleeding
Chief Complaint:
 HISTORY OF
PRESENT ILLNESS
 Five months prior to admission, at 8 weeks AOG, the patient noted onset of
nausea and vomiting, three to four episodes a day, approximately 1 cup per episode.
This was associated with body malaise. No fever, abdominal pain, vaginal spotting, or
abnormal vaginal discharges. The patient claims this is due to intense smell of food
and perfumes. No interventions were done.

Three months prior to admission, the symptoms subsided and the patient noted
weight loss of 44kgs to 41kgs. No fever, abdominal pain, vaginal spotting, or abnormal
vaginal discharges. In addition, the patient had her prenatal check-up, upon Doppler
ultrasound, no fetal heart tones were detected thus she was advised for
Transabdominal Ultrasound, and findings showed intrauterine fetal demise, breech
presentation, 17 weeks by composite aging; Placenta posterior, Grade I, High lying;
Normohydramnios. She was then scheduled for a weekly check-up.
 One day prior to admission, the patient had her check-up, Internal examination
was done and claimed findings of 1 cm dilatation of the cervix. When she got home,
she noted sudden onset of painless irregular uterine contractions between 20 minutes
to an hour. At 9 PM she noted sudden hypogastric pain, sharp in quality, ps 8/10
associated with heavy vaginal bleeding, fully soaking her diaper, and chills.

Upon arrival at UCMed ER, internal examination was done and resulted with a 3
cm dilatation, speculum exam was also done, and showed blood with blood clots
approximately 300cc. The fetus and the placenta was found in the patient’s diaper
thus was advised for admission and completion curettage.
COMPLETE PHYSICAL
EXAMINATION
 General survey & vital signs

General Survey: Patient is conscious, alert, coherent and not in respiratory distress. She is well
groomed with no unusual odors. Good posture and gait and is oriented to time place and
person, and is dressed appropriately.

● BP: 100/60 mmHg (right arm, sitting) HR: 65 BPM

● RR: 20 Cycles/ Minute Temp: 36.2 C (axillary)

● Weight: 41 kgs Height: 154 cm

● BMI: 17.3 (Underweight) O2 sat: 99% via room air

Skin: Fair in complexion. No cyanosis, no bruises, no hematomas, no scars, no edema. Skin is
warm and moist with good mobility and turgor.

HEENT:

Head: No flakes on the scalp, no lumps, and no lesions. Skull is normocephalic and
symmetrical. Hair is black and evenly distributed. No depression or tenderness. Face has no
involuntary muscle movements. Skin on face is smooth, no jaundice and no swelling.

Eyes: Eyeballs non-sunken. Right and left eye well aligned with no deviation, right eye with
pterygium. Pink palpebral conjunctiva and anicteric sclerae, non-puffy eyelids.

Ears: Auricle and surrounding tissues are not tender and not erythematous; no lesions noted.
Ear canal has no lesions and there are no discharges. Tympanic membrane with good cone of
light.

Nose and Paranasal Sinuses: No deformities, no alar flaring and no discharges. Nasal mucosa
is pink and septum is in midline. No paranasal sinus tenderness.
Neck: No scars nor enlargements. No lymphadenopathy. Trachea is at midline. Neck veins not
engorged. Thyroid gland non palpable.

Chest and Lungs: Chest has normal AP diameter and there are no bony deformities. There are
no intercostal retractions. There is full and symmetrical lung and chest expansion. Lungs are
resonant to percussion. Vesicular breath sounds are noted upon auscultation. No rhonchi,
rales, crackles, stridor or wheeze.

Cardiovascular: Carotid upstroke is brisk and no bruits heard. There are no palpable heaves,
lifts, and thrills. Regular rate and rhythm. S1 and S2 are distinct. No murmur heard. JVP not
measured.

Abdomen: Flabby, soft, normoactive bowel sounds, non-tender upon light and deep palpation
in all quadrants

GUT: IE: 3 cm dilatation, and soft consistency of cervix

PVS: Extremities are warm and dry. No cyanosis, no varicosities and no edema. The calves are
supple and nontender. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial
pulses are 2+ symmetrical. CRT in both upper and lower extremities is less than 2 seconds.

Musculoskeletal: No degenerative changes, no muscle wasting. Spine is straight with no joint

tenderness.

Neurological:

Mental Status: Patient appears normal, well-groomed and cooperative. She is oriented to
person, time and place. Recent and remote memory intact. Thought process, content and
insight intact. She can perform calculations. No agnosia, no apraxia and no aphasia.
 NEUROLOGIC EXAMINATION:
Cranial Nerves:

II: Pupil equal, round, reactive to both light and accommodation 20/20 Visual acuity by jaegers
chart

III, IV, VI: Extraocular muscles are intact

V: temporal and masseter strength intact, (+) corneal reflex

VII: no facial asymmetry

VIII: able to hear whispered voice at 2ft

XI: Able to shrug shoulders bilaterally against resistance

Motor: Good muscle bulk and tone. No atrophy noted through comparison of both left and
right muscle groups. All muscle strength graded 5/5.

Cerebellar: Finger-to-nose test and rapid alternating movement are good

Sensory: Pinprick, light touch, and stereognosis are intact

THANK YOU
Danke
merci
ありがとうご
ざいます
감사합니다
Dr. PESONS