Professional Documents
Culture Documents
• 41/M
• G3P2(2002)
• CC: labor pains
• 1 day prior to admission, patient had onset of irregular uterine contractions
occurring 1-2 episodes in an hour, lasting ~30 seconds, mild in intensity.
Patient had her Scheduled PNCU and IE was done revealing closed cervix.
Patient was advised admission for induction of labor.
• (+) active fetal movements
• (-) watery vaginal discharge
• (-) vaginal bleeding
PAST MEDICAL HISTORY
(-) Hypertension
(-) Diabetes Mellitus
(-) Bronchial Asthma
(-) Thyroid/ Cardiac disorder
(-) Previous surgery
(-) FDA
FAMILY HISTORY
(+) Hypertension- paternal side
(+) Diabetes Mellitus- paternal side
(+) Congestive Heart Failure- Father
(-) Bronchial Asthma
(-) PTB
(-) Cancer
MENSTRUAL HISTORY
Menarche: 12 years old G1-2007-F-FT- NSVD-6lbs 3 oz-RMC
Interval: regular G2-2008-F-FT- NSVD-5lbs 13 oz-RMC
Duration: 7 days G3-present pregnancy
Amount: 3-4 pads/day, moderately soaked
Symptoms: (-) dysmenorrhea LMP: Sept 10, 2017
AOG: 41 1/7 weeks by LMP
Coitarche: 28
EDC: June 17, 2018 by LMP
# SP: 1
Family planning: Calendar method
(+) OCP use- 2010- Ethinyl estradiol +
Levonorgestrol (Trust pills) x 3 months
Papsmear- 2017- unremarkable
OB Course:
1st PNCU: 1 month AOG w/ AP, total of >10 visits
4 weeks AOG- threatened abortion- Isoxuprine (Isoxilan) 10mg/tab, 1 tab TID x
2 weeks
8 weeks AOG- URTI- Nasathera BID x 5 days
12 weeks AOG- threatened abortion- Isoxuprine (Isoxilan) 10mg/tab, 1 tab TID x
2 weeks
FAMILY HISTORY
(+) Hypertension- both sides
(-) Diabetes Mellitus
(+) Myocardial Infarction- maternal side
(-) Bronchial Asthma
(-) PTB
(-) Cancer
MENSTRUAL HISTORY
Menarche: 13 years old
Interval: regular LMP: Oct 4, 2017
Duration: 4-5 days AOG: 36 5/7 weeks by LMP
Amount: 2 pads/day, moderately soaked 37 1/7 weeks by UTZ
Symptoms: (+) dysmenorrhea EDC: July 11, 2018 by LMP
Coitarche: 31
# SP: 1
(-) OCP use
(-) Papsmear
OB Course:
1st PNCU: 5 weeks AOG w/ AP, total of >10 visits
8 weeks AOG- URTI (nasal catarrh & cough)- no meds given
20 weeks AOG- cough- no meds given
UTI- unrecalled antibiotics BID x 7 days