PGI AMER HUSSIEN P.

SAMPORNA

Our Lady of Lourdes Hospital
Department of Obstetrics and Gynecology

May 7, 2014
Identifying Data
Patient is Daisy Jane A. Legaspi 36 year old G2P1 (1001), married, pharmacist, Filipino,
currently residing in Sta. Mesa, who was admitted for the 2
nd
time at OLLH on May 6, 2014.
Chief Complaint
Vaginal Spotting
History of Present Pregnancy
LMP: March 23, 2014
EDC: December 28, 2014
AOG: 6 weeks and 2 days
History of Present Problem
13 days prior to admission, patient started to notice vaginal spotting and uses 2-3 pads
per day with blood stained of 3 finger breadths for 5 days. She did not consult and no
medications were taken. Patient was apparently well until 1 day prior to admission her vaginal
spotting returned and uses 2-3 pads per day with blood stained of 5 fingerbreadths. She seek
consult at OLLH emergency department and was given with Isoxilan tab 3 times a day and was
sent home.
Few hours prior to admission her vaginal spotting persisted. She was sent to OLLH
emergency department and was assessed by Dra. Managuelod. She underwent transvaginal
ultrasound which revealed ectopic pregnancy hence she was subsequently admitted for
possible salpingectomy.
Antenatal History
Patient had monthly prenatal check up with Dra. Managuelod.
Past Medical History
Patient denies of having hypertension, diabetes, bronchial asthma, COPD, PTB, allergy,
cancer, coronary disease, heart failure, arthritis, skin disease, blood dyscrasia, thyroid disease,
kidney disease and neuro-psychiatric disorders.
PGI AMER HUSSIEN P. SAMPORNA

2012 she was diagnose to have acute gastritis and was given with Omeprazole 40
mg/tab once a day.
Family History
Her mother was diagnosed to have diabetes. She denies other heredo familial diseases
like hypertension, asthma, kidney disease, allergy, cancer and live diseases.
Personal and Social History
She is a non-smoker, non-alcoholic beverage drinker and denies use of illicit drugs.
Menstrual History
Menarche at the age of 13, regular menstruation, 3-5 days , uses 2-3 pads per day
moderately soaked and she has no dysmenorrhea.
Sexual History
She had her first sexual intercourse at the age of 18. She and her husband do not use
any contraceptive method.
OB History
G2P1(1001)
G1: (2010) Pregnancy Uterine Full Term via Normal Spontaneous Vaginal Delivery at
OLLH, with no feto-maternal complications
G2: (2014) Present Pregnancy
Review of Systems:
General: no weight loss or easy fatigability
CNS: No headache or dizziness
Respiratory: no difficulty of breathing, any colds or cough
Cardiovascular: No chest pain and no palpitations
Gastrointestinal: No diarrhea, nausea, vomiting, or constipation
Genitourinary: No dysuria, polyuria, hematuria or urinary urgency, no discharge
Extremities: No weakness or numbness
Psychiatric: No mood changes, depression or suicide attempts

PGI AMER HUSSIEN P. SAMPORNA


Physical Examination:
General Survey: Conscious, coherent and not in cardiorespiratory distress.
Vital Signs : BP 120/90 mmHg,
HR: 89 bpm,
RR: 18cpm
Temp: 36.5 C.
HEENT:
Head: normocephalic, no scars, no contusion no lesions
Eyes: anicteric sclerae, pinkish palpebral conjunctiva, pupils briskly reactive to light, 2-3
mm
Nose: no discharge, nasal septum midline, no nasal flaring
Mouth: pink oral mucousa, no exudates no lesions
Neck: no lymphadenopathy, no mass, no swelling, thyroid not enlarge
Throat: no tonsillar swelling
Thorax and Lungs: symmetrical, no retraction, no use of accessory muscle, Equal chest
expansion, Clear breath sounds
Cardiovascular: adynamic precordium , regular rhythm and rate , distinct heart sound, no
murmur
Abdomen: soft , flat, direct tenderness on right lower quadrant, normoactive bowel sounds
Extremities: no deformities, no cyanosis , <2 sec capillary refill time, no edema, full pulses
Neurologic: Intact cranial nerves, good muscle tone, no motor and sensory deficits
IE: cervix is closed, no cervical motion tenderness, with blood per examining finger, with
tenderness on left adnexa
ADMITTING DIAGNOSIS:
Ectopic Pregnancy 6 2/7 weeks AOG
PGI AMER HUSSIEN P. SAMPORNA

G2P1 (1001)
PLAN:
Admit patient
Monitor vital signs
Do transvaginal ultrasound
Medical Management:
Methothrexate for rapid absorption of placental tissues
Surgical Management:
Request for CBC, 12L ECG, Protime, Blood typing, serum electrolytes, BUN and Crea, HBsAg
Partial Salpingectomy, Salpingostomy, Salpingotomy