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the lumbosacral area No passage of blood or watery vaginal discharge Consult with an OB
Abdominal exam: (+) uterine contractions IE: cervix soft, short, closed P> advised admission
Impression
Single , live, intrauterine pregnancy, cephalic, 25
weeks AOG, w/ good cardiac & somatic activity; Cervical funneling (0.85cm)
ADMISSION
Prenatal Check-ups
Prenatal check up at USTH-MAB, ~3x
1st
Fetal
Single,
CBC-
FBS
1st hr 2nd hr
66.8 mg/dl
145.0 mg/dl 110.0 mg/dl
3rd hr
112.0 mg/dl
Review of Systems
No anorexia, weight loss No fever No cough No hearing loss, nasal congestion No polyuria, polydipsia, polyphagia No cyanosis No chest pain No diarrhea, no constipation No dysuria, incontinence
No allergies
No previous hospitalization No previous surgeries
Family History
(+) Diabetes Mellitus - mother (+) Thyroid disease mother (+) Hypertension father
Menstrual History
Menarche
13 years old Interval 60-90 days Duration 7 days Amount 4-5 pads per day, moderately soaked (+) D1 & D2 Dysmenorrhea
Sexual History
First sexual contact at 18 years old 3 sexual partners Family planning method: condom, withdrawal
Physical Examination
Conscious, coherent BP 110/80 PR 80 RR 19 T 36.5 Ht 150 cm Wt 52 kg Warm, moist skin; no active dermatoses Pink palpebral conjunctivae, anicteric sclerae Neck not rigid, no palpable lymph nodes, thyroid not enlarged Symmetrical breasts, no palpable masses nor tenderness, no nipple discharge, no axillary lymphadenopathy
Physical Examination
Adynamic precordium, AB at the 5th LICS, MCL,
No murmurs Symmetric chest expansion, no retractions, clear breath sounds Globular abdomen, FH 24 cm, FHT 142 bpm Speculum Exam: cervix violaceous, smooth, w/ minimal whitish mucoid discharge IE: cervix: soft, short, closed uterus: enlarged to 6 months
edema
Assessment
Pregnancy 24-25 weeks AOG, threatened preterm labor
Laboratory Tests
CBC Hemoglobin Hematocrit WBC Segmenters Lymphocytes Platelet 99 0.28 14.5 0.89 0.11 300
Laboratory Tests
Urinalysis (9/8/08)
Color Transparency Ph Specific gravity Albumin sugar RBC Pus cell Squamous cell Bacteria Mucus threads Amorphous urate yellow Sl. turbid 7.0 1.010 NEGATIVE NEGATIVE 0-1/hpf 3-5/hpf ++ FEW FEW +++
Plans
Problem #1: Pregnancy 24-25 weeks, threatened preterm labor 1. Complete bed rest, no bathroom privileges 2. Continue tocolysis - 4 ampules Isoxsuprine HCl in 500cc D5W to run at 20ugtts/min to titrate at increments of 5 ugtts/ min 3. For cerclage
st 1
HD: 9/25/08
S> Good fetal movement No hypogastric pains No bloody or watery vaginal discharge O> BP 110/80 PR 84 RR 18 T 36.5 FHT 148 bpm No uterine contractions P> Continue IV Tocolysis
O> BP 110/80 PR 72 FHT 146 bpm P> Continue IV tocolysis Cerclage done
RR 19
T 36.6
RR 18
T 36.6
P> Continue IV Tocolysis Start Isoxilan HCl 10 mg/tab, 1 tab q8 hrs For cervical length & funneling determination
Impression
Funnel length 1.60 cm NARROW BUT DEEP U
FUNNEL Functional cervical length 1.72 cm Hyperechoic foci 1.2 cm from the external os (sutures)
P> Continue Isoxilan tablet q 8 hrs Measure fundic height and weight weekly