Placenta PREVIOUS

Lapasaran, Michael Lou

Sunga, Toni Mikee
Uy, Camille Marie
 Patient Information
J.M.R
21
Single
Tibungco, Davao City
Roman Catholic
 Chief Complaint
Vaginal Bleeding
History of Present Illness
History of Present Illness
History of Present Illness
History of Present Illness
 Past Medical History
(-) Diabetes Mellitus
(-) Hypertension
(-) Bronchial Asthma
(-) Heart Problems
(-) Thyroid Problems
Family History
 Personal And Social History
Non-smoker, non - alcoholic beverage drinker
College Graduate
Unemployed
 Obstetric History
Pregnancy Outcome/ Year Gestation Sex Birth Weight Present Status Complications
Order Delivery Completed
G1 NSVD 2015 Full Term M 2.3 kg Living None
G2 Present
Pregnancy
 Obstetric History
Last Menstrual Period: December 18, 2016
Previous Menstrual Period: November 18, 2016
Estimated Date of Confinement: September 24, 2017
Age of Gestation: 33 3/7 weeks
Date of Quickening: 2nd week of April 2017 (sure ni? 4
months?)
 Obstetric History
Ultrasound Date: June 2017
Age of Gestation: 21 weeks
Ultrasound EDC: October 17, 2017 ( 2 weeks)
Desired number of children: 2
Antenatal Visits: Health Center x 3
Immunizations: (-) Tetanus, (-) Hepatitis B
Prenatal Blood Pressure: 120/80 mm Hg
Vitamins: Ferrous Sulfate
 Gynecologic History
Menarche: 11 years old
Interval: Monthly
Duration: 3 days
A???: 2 pads
Symptoms: (-) Dysmenorrhea
 Review of Systems
General (-) general weakness, (-) recent changes in weight

Dermatologic (-) excessive sweating, rashes

Neuromuscular (-) hand tremors, (-) proximal muscle

weakness, (-) easy fatigability

Cardiovascular (-) Palpitations

 Review of Systems
Respiratory (-) Dyspnea, cough, coryza

Gastrointestinal (-) Increased bowel motility with increased

frequency of bowel movements

Genitourinary (-) dysuria, (-) burning sensation in urethra, (-)

frequency, urgency, nocturia, hematuria

Ophthalmologic (-) Tearing, gritty sensation in the eye,

photophobia, eye pain, protruding eye, diplopia, visual loss
 Review of Systems

Metabolic (-) Heat intolerance, (-) weight loss

Psychiatric (-) Restlessness, anxiety, irritability, insomnia

 Vital signs:
BP 100/60 mmHg
HR 108 bpm
RR 22 cpm
Physical Examination Temp. 36.60C
Wt. 49 kg
Ht. 147 cm
BMI

General: conscious, coherent, not in respiratory distress

 Physical Examination
Skin: fair, no discolorations, no rashes

Lymph nodes: no lymphadenopathies

Skull: normocephalic, no depressions, no lesions

 Physical Examination
Eyes: anicteric sclerae, pink palpebral conjunctiva

Ears: pinnae in line with outer canthi of both eyes, instant recoil,
no deformities, no discharge

Nose: nasal septum at midline, no discharge, nontender

Mouth/Throat: no gum bleeding, no sores, no tonsillopharyngeal

congestion
 Physical Examination
Neck: No discolorations, no bruises, no tracheal deviation, no neck vein
engorgement

Breast: symmetrical, no discolorations, no dimpling, no masses, no discharge

Chest: no lesions, no deformities, equal chest expansion, clear breath sounds

Vascular: full and equal pulses

Cardiac: adynamic precordium, distinct heart sounds, normal cardiac rate and
regular rhythm, no murmurs
 Physical Examination
Abdomen
Fundic Height: 26 cm
L1: breech
L2: fetal back at maternal right
L3: cephalic???
Fetal Heart Tone: 132 beats per min

Estimated Fetal Weight: 2.3 kg

 Physical Examination

Genitourinary:

Rectum:

Extremities: no deformities, no edema, no cyanosis, full range

of motion
 Pelvic Examination
(+) blood clots on speculum exam
_______ cervix
(-) uterine contractions
Intact Bag of Water
NO INTERNAL EXAM DONE
 Musculoskeletal
o No pathologic reflexes
100% 100%
5/5 5/5

++ ++
++ ++

5/5 5/5

++ ++ 100%
100%

++ ++
Salient Features
G2P1 (1001) Pregnancy Uterine 33 3/7 weeks
Age of Gestation, Cephalic Not in Labor, To
Consider Placenta Previa
Differentials
Final Diagnosis
Discussion