OB-CASE

PRESENTATION
3
rd
yr
Aruchamy, Sudharsan
Augustus, Joel
Khadhar, Basha
Ganeshan, Kishore
Austin, Nissy
GENERAL DATA
PR
28 years /G1P0
Married
Davao City
Catholic


CHIEF COMPLAINT




VAGINAL BLEEDING
HISTORY OF PRESENT ILLNESS

2 Hour PTA
Spotting Vaginal Bleeding
Pain(-)
Fluid discharge(-)
Headache(-)


OB/GYN HISTORY,
PREGNANCY NO: PREGNANCY
OUTCOME
1. PRESENT PREGNANCY
G1P0 (F0 P0 A0 L0)
G1P0 (F0 P0 A0 L0)
LMP July 24,2013
EDC - May 1, 2014
AOG 40 weeks and 6days.

Prenatal check ups:-

1
st
- 2
nd
month (8 week AOG)
2
nd
6
th
month (24 week AOG)
MD
ANTENATAL ILLNESS

URINALYSIS:-
(+)UTI- December 2013, @ 20week AOG-
Treatment- Amoxicillin 21capsules/7days

CBC - Unrecalled

Vitamins/supplements From 8 week AOG

Folic acid- OID
Iron-OID
IMMUNIZATION
TT - 2 doses
TT1 - January (24 week AOG)
TT2 February (28week AOG)

Hepatitis(-)
GYNE HISTORY
MENSTRUAL HISTORY
Menarche 11yrs old
Regular
28 Days /3-4 days/ 2-3 pads per day

COITERACHE : 25 yrs. old
No of sexual Partners 1
No history of Contraceptive use
PAST MEDICAL HISTORY



No prior surgeries or hospitalizations
No History of HPN, DM or other disease
FAMILY HISTORY


Maternal HPN(-)
DM (-)
Asthma(-)
Allergies(-)
Arthritis(-)
Cancer(-)
PERSONAL/SOCIAL HISTORY


Married
College graduate
Working as a teacher
Non smoker
Non alcoholic drinker
REVIEW OF SYSTEM
GENERAL
(-) fever,
(-) body malaise,
(-) sweats,
(-)anorexia ,
(-) weight change,

Pre pregnancy weight - 51kg
Present weight 56kg
Total weight gain 5kg


EYES:-
(-) Visual dysfunction, itching, redness or pain

EAR:-
(-) Deafness or discharge

Nose:-
Midline
(-)Epistaxis, obstruction, discharges
MOUTH:-
(-) Bleeding gum

THROAT:-
Midline Trachea

ABDOMEN:-
(-) Nausea, vomiting, diarrhea

NECK:-
(-) stiffness, limitation in motions

PULMONORY SYSTEM
(-) respiratory problems

CADIAC
(-) Problems

NEUROLOGIC
(-)stiffness, seizures or fainting
PHYSICAL EXAMINATION


GENERAL
Awake, oriented, Conscious,
Coherent and Cooperative,
Not in labor
Not in respiratory distress

VITAL SIGNS
TEMP 37 degree Celsius
PR 70 beats/min
RR 16 breath/min
BP 120/80

SKIN, HAIR, NAILS
(-) Skin rash, cyanosis, clubbing, pallor, bruise
Normal hair distribution

HEAD
Normo cephalic
(-) No lesions
EYES
Anicteric sclera, pupils reactive to light, palpebral
conjunctiva pink

EARS
Symmetrical external ears
(-) Discharges

NOSE
(-)Nasal deviation, discharges, tenderness


MOUTH
(-) Bleeding gums

NECK
(-) Tracheal deviation, neck masses


THORAX AND LUNGS
symmetrical lung expansion
(-) retraction, tenderness, palpable mass, wheezing,
crackles

CVS system
No murmurs on auscultation

BREAST
Not examined

ABDOMEN
Inspection
Globular
(-)Abdominal striae, rashes
Linea Nigra
FH- 39cm




AUSCULTATION
FHT 130 - 140beats/min

PALPATION
LEOPOLDS MANEUVER:

L1 Fetus small parts
L2 Fetal head at right side
L3- Floating
L4 - Not assessed



PELVIC EXAMINATION
Not assessed
SALIENT FEATURES
28 yrs. old
G1P0
AOG - 40 weeks and 6 days
Spotting bleeding with no pain and fluid discharge
FH 39cm
LEOPORDS MANEUVER
L1- Fetal small parts palpated
L2- fetal head at right side
L3- floating

ADMITTING IMPRESSION



Pregnancy uterine, 40 weeks and 6 days age of
gestation, with transverse position, and not in labor
G1P0

DIFFERENTIAL DIAGNOSIS
PLACENTA ABRUPTION
RULE IN:

Bleeding

RULE OUT
No contraction
No pain
No tenderness in abdomen


VASA PREVIA
RULE IN:
Bleeding
No pain

RULE OUT:
No membrane rupture
No Multiple pregnancy

Cervicitis
RULE IN:
Vaginal spotting bleeding

RULE OUT:
no mucopurulent discharges

Premature Rupture of Membrane
RULE IN:
Bleeding

RULE OUT
No fluid discharge
No rupture of membrane
PLACENTA PREVIA


RULE IN

Painless, bright red vaginal bleeding
>32 week of gestation
Fetus transverse position
WORKING DIAGNOSIS



P.R, 29 yrs. old, G1P0(1 0 0 0), pregnancy uterine 39
week and one day AOG, transverse presentation of
fetus, not in labor with PLACENTA PREVIA..

MANAGEMENT


Cesarean section