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					OSPITAL NG MAYNILA MEDICAL CENTER Department of Obstetrics and Gynecology

Date: April 4, 2007 Hospital No: 1424760 Name: Cabading, Lucenda Age/ Sex: 29/ F Address: 1422 St. Gabriel St. Baclaran, Paranaque City Date Admitted: April 1, 2007 Admitting Diagnosis: G1P0 PU 37 6/7 wks AOG CIBL, Preeclampsia Severe Final Diagnosis: G1P1 (1001) PU delivered spontaneously to a live full term baby boy, Preeclampsia Severe Referred to: Department of Internal Medicine Reason for referral: For cardiac evaluation

Referring Physician: ________________________________ Drs. Sibug/Angeles/ Reyes/Cortes/Cister

Receiving Physician: ________________________________

Ospital ng Maynila Medical Center Department Obstetrics and Gynecology

Date: April 4, 2007 Hospital No: 1424760

Name: Cabading, Lucenda Age/ Sex: 29/ F Address: 1422 St. Gabriel St. Baclaran, Paranaque City Date Admitted: April 1, 2007 Admitting Diagnosis: G1P0 PU 37 6/7 wks AOG CIBL, Preeclampsia Severe Final Diagnosis: G1P1 (1001) PU delivered spontaneously to a live full term baby boy, Preeclampsia Severe Residents In-Charge: Drs. Sibug/Angeles/ Reyes/Cortes/Cister

Clinical Abstract

This is a case of a 29 y/o female from Sampaloc, Manila who came in due to watery vaginal discharge. Few hours prior to consult, patient had watery vaginal discharge accompanied by bloody show with good fetal movement, thus prompted consult. REVIEW OF SYSTEMS: No weight loss, no weight gain No headache No vomiting, no dysphagia No cough, no colds No difficulty of breathing No palpitations, no orthopnea No melena No urinary urgency/frequency No loss of consciousness, no seizures PAST MEDICAL HISTORY: (-) HPN (-) DM (-) Goiter FAMILY MEDICAL HISTORY (-) HPN (-) DM (-) ASTHMA, ALLERGIES (-) HEART DISEASE PERSONAL AND SOCIAL HISTORY Non-smoker, non-alcoholic beverage drinker MENSTRUAL HISTORY M – 16 y/o I – regular D – 3-5 days

A – 5 pads per day S – (-) dysmenorrhea SEXUAL HISTORY Coitarche: 28 y/o No. of sexual partners: 2 (-) OCP use (-) Dyspareunia (-) PCB (-) STD OB HISTORY G1P0 G1 – PP, (+) PNCU x 4, (+)meds: Methyldopa q6 PHYSICAL EXAMINATION General: Conscious, coherent, ambulatory, and not in cardiorespiratory distress BP: highest BP – 180/130, latest BP – 160/110 PR: 76 RR: 20 T: 36.5 C HEENT: Anicteric sclerae, pale palpebral conjunctiva, no nasoaural discharge, no tonsillopharyngeal congestion, no cervical lympadenopathy CHEST/LUNGS: Symmetrical chest expansion, no lagging, no retractions, clear breath sounds HEART: Adynamic precordium, normal rate and rhythm, no murmurs ABDOMEN: Globular, normoactive bowel sounds EXTREMITIES: Grossly normal, full and equal pulses, no edema, no cyanosis


				
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