De La Salle University Medical Center Department of Obstetrics and Gynecology
De La Salle University Medical Center Department of Obstetrics and Gynecology
De La Salle University Medical Center Department of Obstetrics and Gynecology
CLINICAL HISTORY
GENERAL DATA
L.T., 23 years old, G1P0, married, Filipino, Roman Catholic, from Cavite, consulted the DLSUMC-ER on
February 10, 2021
CHIEF COMPLAINT
Labor pains
FAMILY HISTORY
No history of allergy, diabetes mellitus, asthma, heart disease, cancer, tuberculosis, hepatitis, multifetal
pregnancies nor congenital anomalies in the family
MENSTRUAL HISTORY
The patient had her menarche at 13 years old. Her menses are regular that lasts 7 days. She reports
using up to 8 moderately soaked napkins a day with no dysmenorrhea.
GYNECOLOGICAL HISTORY
No papsmear
No history of infection, disease or surgery of the female reproductive tract
SEXUAL HISTORY
Patient had her first sexual contact at 21 years old with two (2) lifetime sexual partner. No post-coital
bleeding nor any other signs and symptoms associated with coitus.
CONTRACEPTIVE HISTORY
None
2DED (7/7/2020)
The left ventricle is normal in dimension with adequate wall motion and normal systolic function
The left atrium, right atrium and right ventricle are normal
Normal mitral valve, aortic valve and pulmonic valve
There is no pericardial abnormality noted
IMPRESSION
Normal left ventricle
Mild mitral regurgitation
One hour prior to admission, patient noted regular contractions coming in every 3-5 minutes, lasting for 30-
50 seconds, moderate to strong in intensity. There was noted good fetal movement, no spotting or watery discharge
noted. Due to progression of uterine contractions patient consulted at the emergency room. Upon arrival at the ER,
she has uterine contractions every 2-3 minutes lasting for 30-60 seconds, moderate to strong in intensity. She has
stable vital signs. She has no cough, colds, fever, palpitation or difficulty of breathing. On IE, cervix was 4cm dilated,
60% effaced, intact bag of water, cephalic, station -2.
REVIEW OF SYSTEMS
o General: (-) weight loss, (-) poor activity, (-) loss of appetite
o Integument: (-) pruritus, (-) acne, (-) nail clubbing
o HEEN: (-) vision difficulties, (-) use of glasses, (-) lacrimation, (-) hearing difficulties, (-) ear pain, (-) ear
discharge, (-) frequent colds, (-) nasal discharge, (-) mouth sores, (-) epistaxis, (-) toothache
o Neck and Throat: (-) lymphadenopathy, (-) mass, (-) muscle stiffness, (-) muscle weakness, (-) frequent sore
throat
o Cardiovascular: (-) cyanosis, (-) fainting spells
o Respiratory: (-) cough, (-) dyspnea, (-) chest pain
o Gastrointestinal: (-) abdominal pain, (-) loose stool, (-) vomiting, (-) diarrhea, (-) constipation
o Genitourinary: (-) dysuria, (-) discharge
o Endocrine: (-) cold intolerance, (-) heat intolerance, (-) polydipsia, (-) polyuria (-) polyphagia
o Nervous/Behavioral: (-) weakness, (-) sleep problems, (-) seizures, (-) eating problems,
(-) mood/personality changes
o Musculoskeletal: (-) limitation of motion, (-) muscle pain, (-) joint pain, (-) edema
o Hematopoietic: (-) pallor, (-) bleeding, (-) easy bruisability
PHYSICAL EXAMINATION
GENERAL SURVEY
Patient is well developed, well nourished, conscious, coherent, oriented to place, person and time, in no
cardiorespiratory distress, appears her chronological age of 23 and ambulant.
VITAL SIGNS
BP = 110/80mmHg
HR = 82bpm
RR = 20cpm
Temp = 36.5°C
GENITALIA/CLINICAL PELVIMETRY
External genitalia grossly normal. Vagina is non-parous, cervix dilated to 4cms, 60% effaced, intact
membranes, cephalic, station -2. Noted mucoid bloody discharge per finger.