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					OSPITAL NG MAYNILA MEDICAL CENTER Department of Obstetrics and Gynecology

Hospital No: 1645155 Name: Villarino, Juliet Age/Sex: 20/F Address: Old Sta.Mesa St. Manila Date Admitted: April 28, 2007 Admitting Diagnosis: G1P0 11 weeks AOG T/C threatened abortion Residents In-Charge: Drs. Alvarez/Castillo-Pantoja/Pineda/Reyes/Tovera

Clinical Abstract This is a case of J.V., G1P0, 20 y/o female who came in due to vaginal bleeding. Three days PTC, patient had vaginal bleeding with associated abdominal pain. No vaginal or watery discharge was noted. Two days PTC, patient had minimal vaginal spotting with abdominal pain. One day PTC, persistence of minimal spotting and abdominal pain prompted consult. REVIEW OF SYSTEMS: No fever, weight loss, no weight gain No headache No vomiting, no dysphagia No cough, no colds No difficulty of breathing No palpitatons, no orthopnea No melena No dysuria, urinary urgency/frequency No loss of consciousness, no seizures PAST MEDICAL HISTORY: (-) HPN, DM, asthma, goiter FAMILY MEDICAL HISTORY: No knowm heredofamilial disease PERSONAL & SOCIAL HISTORY: non-smoker, non-alcoholic beverage drinker MENSTRUAL HISTORY: M – 15 y/o I – irregular D – 3-5 days A – 3 pads per day moderately soaked S – (+) dysmenorrhoea SEXUAL HISTORY: Coitarche at 20 years old, with 1 sexual partner, no history OCP or IUD use, no dyspareunia or post coital bleeding, no history of sexually transmitted disease. OB HISTORY: G1P0 G1 – PP, (-) PNCU PHYSICAL EXAMINATION: General: Concious, coherent, ambulatory, and not in cardiorespiratory distress. BP: 100/60 PR: 80 RR: 20 T: 36.8 ºC HEENT: Anicteric sclerae, pale palpebral conjunctivae, no nasoaural discharge, no tonsillopharyngeal

congestion, no cervical lymphadenopathy CHEST/LUNGS: Symmetrical chest expansion, no lagging, no retractions, clear breath sounds HEART: Adynamic precordium, normal rate and rhythm, no murmurs ABDOMEN: slightly globular, normoactive bowel sounds, (+) pain in the inguinal area EXTREMITIES: Grossly normal, full and equal pulses, no edema, no cyanosis ASSESSMENT: G1P0 11 weeks AOG T/C Threatened abortion PLAN: CBC with PC, BT, UA, Misoprostol 1 tab per vagina


				
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