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CASE PRESENTATION

CASE PRESENTATION. BAUTISTA, Sherwin ONTOK, Abdul-Aziz RODRIGUEZ, Melissa Beatriz SALONGCAY, Recivall SAMSON, Edgardo. IDENTIFYING DATA. M.V.L. 27 y.o . Female G2P1 (1001) Married Bank Accountant Roman Catholic Makati City October 26, 2009. CHIEF COMPLAINT.

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CASE PRESENTATION

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  1. CASE PRESENTATION BAUTISTA, Sherwin ONTOK, Abdul-Aziz RODRIGUEZ, Melissa Beatriz SALONGCAY, Recivall SAMSON, Edgardo

  2. IDENTIFYING DATA • M.V.L. • 27 y.o. • Female • G2P1 (1001) • Married • Bank Accountant • Roman Catholic • Makati City • October 26, 2009

  3. CHIEF COMPLAINT • Cervix is open already

  4. HISTORY OF PRESENT ILLNESS • LMP: Unsure • EDC by LUTZ: October 30, 2009 • AOG: 37 3/7 weeks by LUTZ

  5. HISTORY OF PRESENT ILLNESS • 6 hours PTA, patient visited her private obstetrician for scheduled prenatal checkup. Upon examination it was noted that she was having irregular uterine contractions and IE revealed an open cervix, 1 cm dilated (-) watery/bloody vaginal discharge (+) good fetal movement

  6. PAST MEDICAL HISTORY • No previous hospitalizations • No previous surgeries • No maintained drugs • No food and drug allergies

  7. FAMILY HISTORY • (+) Hypertension, paternal • (-) Diabetes mellitus • (-) Thyroid diseases • (-) Pulmonary tuberculosis

  8. MENSTRUAL HISTORY • Menarche: 15 year old • Menstruation: • Regular interval, 28 day cycle • 3-4 days duration • 2-3 pads per day • (-) dysmenorrhea

  9. GYNECOLOGIC HISTORY • (-) Breast masses/discharges • (-) history of STD

  10. OBSTETRIC HISTORY • G1 – Nov 2008 – Full term – 1o Low-segment cesarean section for dystocia – PGH – Female – approx. 3 kg – No fetomaternal complications

  11. ANTENATAL HISTORY • 1st PNCU: August 2009 • 2nd PNCU: October 2009 • Quickening: approx. 5 months AOG • (-) nausea/vomiting, (-) headache, (-) blurring of vision, (-) preterm regular abdominal contractions, (-) vaginal bleeding, (-) watery vaginal discharges, (-) dysuria • (+) Ferrous sulfate supplement intake

  12. PSYCHOSOCIAL HISTORY • College graduate • (-) Smoking/alcohol/illicit drug intake • First coitus: 25, 1NPSP • (-) Contraceptive use

  13. REVIEW OF SYSTEMS GENERAL: (-) weight loss, (-) fever, (-) easy fatigability SKIN: (-) rashes, (-) change in color HEENT: (-) headache, (-) dizziness, (-) hoarseness RESPIRATORY: (-) cough, (-) dyspnea CARDIOVASCULAR: (-) orthopnea, (-) palpitations GI: (-) anorexia, (-) nausea/vomiting, (-) diarrhea URINARY: (-) dysuria, (-) frequency NEUROLOGIC: (-) loss of consciousness, (-) seizures ENDOCRINOLOGIC: (-) heat/cold intol., (-) 3Ps of DM PSYCHIATRIC: (-) irritability, (-) depression, (-) anxiety

  14. PHYSICAL EXAMINATION GENERAL: conscious, ambulatory, in pain, not in respiratory distress VITAL SIGNS: BP-120/70 mmHg HR-94 RR-24 afebrile SKIN: (-) pallor/cyanosis, (-) lesions, warm to touch HEENT: pink palpebral conjunctivae, (-) alarflaring NECK: supple, (-) masses, (-) LDA CHEST/LUNGS: symmetrical expansion, clear breath sounds, (-) wheezes/crackles

  15. PHYSICAL EXAMINATION HEART: adynamic prec., regular rhythm, (-) murmur ABDOMEN: flabby, norm. sounds, soft, (-) tenderness FH 30 cm, EFW 2.6-2.8 kg, cephalic, LLQ 140’s EXTREMITIES: (-) edema, equally palp. peripheral pulses PELVIC EXAM: Normal external genitalia; nulliparous vagina; cervix soft, midposition, 1cm dilated, -2 station, beginning effacement; intact BOW, cephalic; uterus enlarged to AOG, (-) AMT, (-) discharges

  16. ADMITTING DIAGNOSIS PU 37 3/7 weeks AOG by LUTZ, cephalic, in labor s/p 1o low-segment cesarean section for dystocia, PGH 2008 G2P1 (1001)

  17. PLAN For repeat low-segment cesarean section under spinal anesthesia

  18. COURSE IN THE WARD

  19. COURSE IN THE WARD

  20. COURSE IN THE WARD

  21. COURSE IN THE WARD

  22. COURSE IN THE WARD

  23. SUMMARY

  24. SUMMARY ON ADMISSION

  25. SUMMARY BEFORE INDUCTION

  26. SUMMARY Midazolam, Ephedrine, PNSS

  27. SUMMARY OR STARTED

  28. SUMMARY OR ENDED

  29. SUMMARY AT PACU

  30. SUMMARY PONV

  31. SUMMARY TO ROOM

  32. SUMMARY

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