1. CC: Watery Vaginal Discharge
A.P.T., 36 y/o G1P0 (0000) weeks AOG
CC: Watery Vaginal Discharge

2. History of Present Illness
1 day PTA
(+) passage of bloody mucoid discharge accompanied by intermittent crampy hypogastric pain
Consult at USTH OB-Gyne OPD
Speculum exam: (+) minimal whitish mucoid discharge and (-) ferning test
Internal examination: cervix 1-2cm dilated, 50% effaced, cephalic, (+) BOW, floating.
Uterine contractions: every 4-8 mins, seconds duration, mild-moderate.
Non-stress test: reactive
LMP: feb 28, weeks age of gestation
Eight hours PTC, patient noticed passage of clear watery vaginal discharge, accompanied by mucoid discharge and crampy hypogastric pain. Consult was done 8 hours later at the OPD where she was advised admission.
No medications taken (+) hypogastric pain radiating to the lumbosacral area (-) watery/bloody discharge (+) good fetal movement

3. History of Present Illness
8 hours PTA
(+) passage of clear watery mucoid vaginal discharge, accompanied by intermittent crampy hypogastric pain
(+) good fetal movement
Consult was done 8 hours later at the OPD where she was advised admission.
LMP: feb 28, weeks age of gestation
No medications taken (+) hypogastric pain radiating to the lumbosacral area (-) watery/bloody discharge (+) good fetal movement

4. LMP: January 18 – 21, 2010
PMP: December 18 – 21, 2010
AOG by LMP: weeks
AOG by ultrasound: weeks

5. Review of systems No weight loss No fever, cough, colds, headache
No pruritus, jaundice, cyanosis, pallor
No nausea or vomiting
No diarrhea, constipation
No dysuria, hematuria, edema
No easy bruisability, epistaxis
No polyuria, polydypsia, polyphagia

6. Past Medical History
2008- Stage 1 Invasive ductal CA, s/p right MRM at Perpertual Help Hospital
no chemotherapy done
negative recurrence during check-ups done every 6 months
No hypertension, diabetes mellitus, asthma, allergies, goiter
No previous blood transfusion
Invasive ductal CA, s/p ® MRM, stage I – 2008 (Perpertual Help Hospital) – no chemo – negative recurrence during check-up every 6 months.
No hypertension, diabetes mellitus, asthma, goiter
No allergies

7. Family History (+) Hypertension – Mother and Father
(+) Bronchial asthma – Maternal Grandfather
(-) cancer, diabetes mellitus, tuberculosis, epilepsy, heart disease

8. Personal and Social History
Non-smoker
Non-alcoholic beverage drinker
Denies illicit drug use or abuse
No exposure to radiation or viral exanthem

9. Menstrual History Menarche: 13 y/o Interval: 28 -30 days
Duration: 3 – 4 days
Amount: 4 pads per day, moderately soaked
Symptoms: No dysmenorrhea
LMP: January 18 – 21, 2010
PMP: December 18-21, 2010
Menarche: 13 years old
Interval: days
Duration: 3-4 days
Amount: 4 pads per day, moderately soaked
Symptoms: (-) dysmenorrhea

10. Marital/Sexual History
First sexual contact at 27 years old
1 sexual partner
No post-coital bleeding or dyspareunia
Family planning method: none
First sexual contact at 27 years old
1 sexual partner
No post-coital bleeding or dyspareunia
Family planning method: none

11. Obstetrical History
G7P5 (5014)
Date
Outcome G1
2010
Present pregnancy

12. 2 months of missed menses No accompanying symptoms noted
3/26/10; 9-10 weeks AOG
S>
2 months of missed menses
No accompanying symptoms noted
(+) pregnancy test done 2 weeks PTC
O>
BP: 110/ PR: 82 T: 37 °C Wt: 135 lbs
Flabby abdomen, soft, non tender
External genitalia: no gross lesions
Speculum exam: pink, smooth with whitish, mucoid, non-foul smelling discharge
IE: cervix is soft, long, closed, uterus enlarged to 10 weeks size, adnexae no mass/tenderness
A>
Pregnancy 9-10 weeks AOG
P>
For CBC, TVS for confirmation of pregnancy; Start multivitamins 1 tab OD; TCB with results of UTZ

13. CBC (5/29/10) Ref range Unit 5/29/10 Hgb 120-170 g/L 129 RBC 4.0-6.0
X10^12/L
3.84
HCT
0.36
Platelet
X10^9/L
321
WBC
8.5
Differential Count
Neutrophils
Segmented
0.56
Lymphocytes
0.39
Monocytes
0.03
Eosinophils
0.02

14. Ultrasound Report (5/29/10)
Single live intrauterine pregnancy of about 18 weeks 0 days AOG, Breech presentation, Normal placental implantation and Amniotic fluid volume
Male
SEFW 212 grams
Amniotic fluid: adequate
Placenta: posterior, high lying, grade 0 in maturity
EDC: October 30, 2010

15. ULTRASOUND PHOTOS

16. (-) danger signs of pregnancy
6/1/10; weeks AOG
S>
(+) weakness, easy fatigability and occasional dizziness(-) no other symptoms noted
(-) danger signs of pregnancy
O>
BP: 90/ PR: T: 37 °C Wt: 145 lbs
Pink palpebral conjunctiva, anicteric sclera
Adynamic precordium, no murmurs
Symmetrical chest expansion, no retractions, clear breath sounds
Globular abdomen, FH 3 finger-breadths above umbilicus,FHT Doppler (+)
A>
Pregnancy weeks AOG
P>
Start Ferrous Sulfate 1 tab OD and Ascorbic acid 1 tab OD
Continue milk BID
Repeat UTZ before next check-up: check uterus and ovaries
Get record of breast surgery referral for follow-up
c/o High risk clinic
FH, LM1, LM2, LM3 not applicable

17. Asymptomatic with no danger signs of pregnancy
07/12/10; 25 weeks AOG
S>
Follow up
Asymptomatic with no danger signs of pregnancy
O>
BP: 100/ PR: T: 37 °C Wt: lbs
Pink palpebral conjunctiva, anicteric sclera
Symmetrical chest expansion, no retractions, clear breath sounds
Adynamic precordium, AB at 5th LICS MCL, no murmurs
Globular abdomen, FH 29 cm, FHT 150 bpm, LM1 cephalic, LM2 fetal back right, LM3 breech
(+) grade 1 bipedal edema
A>
Pregnancy 25 weeks AOG, breech
P>
Continue Multivitamins, FeSO4, I glass of milk OD
For 50g OGCT
TCB after 4 weeks for follow up

18. 08/05/2010
50 grams OGCT: 138 mg/dL

19. Persistence of edema, ascending up to the knees
08/09/10; 29 weeks AOG
S>
Follow up
Persistence of edema, ascending up to the knees
No danger signs of pregnancy
O>
BP: 110/ PR: T: 36.3 °C Wt: lbs
Pink palpebral conjunctiva, anicteric sclera
Symmetrical chest expansion, no retractions, clear breath sounds
Adynamic precordium, AB at 5th LICS MCL, no murmurs
Globular abdomen, FH 33 cm, FHT 148 bpm, LM1 breech, LM2 fetal back right, LM3 cephalic
(+) grade 2 bipedal edema
A>
Pregnancy 29 weeks AOG, cephalic; r/o hydramnios; t/c GDM
P>
For fetal biometry with AFI determination and 100 g OGTT
Continue Multivitamins, FeSO4, I glass of milk OD
TCB with results

20. Fetal Biometry (8/10/10)
Single live intrauterine pregnancy of about weeks AOG, cephalic presentation
Male
BPS 8/8
SEFW 1342 grams
AFI: cm
Placenta: posterior, grade 1 in maturity
Fetal Biometry:
BPD: 7.29 cm
AC: cm
FL: 5.49 cm
FAC: cm

21. 8/23/10 100 grams OGTT: Fasting: 64.8 mg/dL 1st hour: 104.4 mg/dL
2nd hour: 90 mg/dL
3rd hour: 86.4 mg/dL

22. Asymptomatic with no danger signs of pregnancy
08/24/10; 31 weeks AOG
S>
Follow up
Asymptomatic with no danger signs of pregnancy
O>
BP: 100/ PR: T: 36.7 °C Wt: 152 lbs
Pink palpebral conjunctiva, anicteric sclera
Symmetrical chest expansion, no retractions, clear breath sounds
Adynamic precordium, AB at 5th LICS MCL, no murmurs
Globular abdomen, FH 33 cm, FHT 148 bpm, LM1 breech, LM2 fetal back right, LM3 cephalic
(+) grade 1 bipedal edema
A>
Pregnancy 31 weeks AOG, cephalic; Breast CA stage 1
P>
For fetal biometry with AFI determination and 100 g OGTT
Continue Multivitamins, FeSO4, I glass of milk OD
Attend mothers’ class am Saturdays
Retrieve OR tech and record of management of breast CA
TCB after 2 weeks
Edema resolved?

23. 09/06/10 33 weeks AOG
S>
Asymptomatic
(-) danger signs (+) good fetal movement
O>
BP: 110/ PR: T: 36.6 °C Wt: 152 lbs
Pink palpebral conjunctiva, anicteric sclera
Symmetrical chest expansion, no retractions, clear breath sounds
Adynamic precordium, AB at 5th LICS MCL, no murmurs
Globular abdomen, FH 33 cm, FHT 148 bpm, LM1 breech, LM2 fetal back right, LM3 cephalic
(+) grade 1 bipedal edema
A>
Pregnancy 33 weeks, cephalic; Breast CA stage 1 s/p Right MRM 2008; Elderly Primigravid
P>
Continue Multivitamins, FeSO4, I glass of milk OD
Attend mother’s class every Saturday 10 am
TCB after 2 weeks for follow-up

24. 09/27/10 36 weeks AOG
S>
Asymptomatic
(-) danger signs (+) good fetal movement
O>
BP: 110/ PR: T: 36.6 °C Wt: 153 lbs
Right chest: (+) scar, no masses; Left chest: no mass/tenderness
Pink palpebral conjunctiva, anicteric sclera
Symmetrical chest expansion, no retractions, clear breath sounds
Adynamic precordium, AB at 5th LICS MCL, no murmurs
Globular abdomen, FH 36 cm, FHT 122 bpm, LM1 breech, LM2 fetal back right, LM3 cephalic
(+) grade 2 bipedal edema
A>
Pregnancy 36 weeks, cephalic, not in labor; s/p MRM for breast CA stage 1, in remission; t/c GDM
P>
For BPS and 100g OGTT
Continue FeSO4 1 cap OD
Attend mother’s class every Saturday 10 am
TCB with results
Fetal movement counting

25. Fetal Biometry (10/06/10)
Single live intrauterine pregnancy of about weeks AOG, cephalic presentation, BPS 8/8, SEFW 3005 grams; Polyhydramnios
Male
AFI: cm
Placenta: posterior, grade III
Fetal Biometry:
BPD: 8.75 cm
HC: cm
FL: 6.69 cm
FAC: 34 cm

26. 10/06/ weeks AOG
S>
Asymptomatic
(-) danger signs, (+) irregular painless uterine contractions, (+) good fetal movement
O>
BP: 110/ PR: T: 36.6 °C Wt: 153 lbs
Right chest: (+) scar, no masses; Left chest: no mass/tenderness
Pink palpebral conjunctiva, anicteric sclera
Symmetrical chest expansion, no retractions, clear breath sounds
Adynamic precordium, AB at 5th LICS MCL, no murmurs
Globular abdomen, FH 36 cm, FHT 122 bpm, LM1 breech, LM2 fetal back right, LM3 cephalic
(+) grade 2 bipedal edema
A>
Pregnancy 36 weeks, cephalic, not in labor; s/p MRM for breast CA stage 1, in remission; t/c GDM
P>
For BPS and 100g OGTT
Continue FeSO4 1 cap OD
Attend mother’s class every Saturday 10 am
TCB with results
Fetal movement counting

27. 3 days PTC (?) minimal watery vaginal discharge, (-) hypogastric pain
10/6/10; 36 weeks AOG
S>
3 days PTC (?) minimal watery vaginal discharge, (-) hypogastric pain
No consult done
2 days PTC (?) watery vaginal discharge, (+) crampy abdominal pain radiating to the back
Consulted at a lying in clinic: IE: 1-2 cm dilated, (?) BOW
No medications given
Complete bed rest with spontaneous resolution of symptoms
O>
BP: 100/ PR: Wt: 144 lbs FH: 30 cm FHT: 138 bpm
Speculum exam: cervix smooth, violaceous, (+) whitish mucoid discharge (-) pooling, (-) Ferning’s test
IE: cervix 1 cm, 50% effaced, (+) BOW, cephalic, station -3
A>
Pregnancy weeks, cephalic, not in labor; (?) Leaking bag of water; Vulvar varicosities; Seizure disorder; Grandmultipara
P>
For BPS with AFI now
Follow up with results

28. BPS (10/11/10)
Single live intrauterine pregnancy of about weeks in cephalic presentation
BPS 8/8
SEFW 1639 grams
AFI: cm
Placenta anterior, grade 1

30. Urinalysis (9/1/10) Pap Smear (6/22/10) Non specific inflammation
Color
L. Yellow
Transparency
Clear pH
6.0
Sp. Gravity
1.005
Albumin
Trace
Sugar -
RBC
0-2hpf
Pus cell
3-5hpf
Squamous cell
few
Bacteria +
Mucus threads ++

31. ULTRASOUND PHOTOS

32. BPS result noted
Continue Multivitamins, FeSO4 and 1 glass of milk OD
Still for MRI
Follow up with Neuro with MRI results
Mother’s class every Saturday
Follow up after 2 weeks

33. MRI REPORT (10/13/10) Impression:
Consider Mesial Temporal Sclerosis, on the right, clinical correlation and follow up suggested

34. Physical Examination on Admission
Conscious, coherent, not in cardiorespiratory distress
BP 120/ PR RR T 36.5 °C
Weight: 146 lbs Height: cm
Warm moist skin, no active dermatosis
Pink palpebral conjunctivae, anicteric sclerae
Neck not rigid, no palpable cervical lymphadenopathy, no anterior neck mass
Symmetrical chest expansion, no retractions, clear breath sounds, no retractions
Adynamic precordium, AB 5th LICS MCL, S1>S2 at the apex, S2>S1 at the base, no murmurs

35. Globular abdomen, FH 30 cm
LM1 - breech LM2 - FBR LM3 – cephalic
FHT 150 bpm
Uterine contractions every 7 minutes seconds, mild to moderate
IE: cervix 2-3 cm dilated, 50% effaced, (+) BOW, cephalic, floating
Extremities: (-) edema, (-) cyanosis; pulses full and equal

36. Neurologic Exam
Alert, awake, oriented to 3 spheres GCS 15 (E4V5M6)
Intact cranial nerves
MMT: 5/5 on all extremities
Can do APST, FTNT with ease
DTRs ++ on all extremities
No sensory deficit
No Babinski
No nuchal rigidity, Brudzinski, Kernigs

37. Assessment Pregnancy 33-34 weeks cephalic, in preterm labor
Seizure disorder

38. Plans CBC with platelet Urinalysis LAT
Refer to Neurology for further evaluation and management
Watch out for recurrence of seizures

39. LAT (10/18/10)

41. A> Pregnancy 33-34 weeks, cephalic, in
preterm labor
Mesial temporal sclerosis
P> Start Isoxsuprine drip (4 ampules in 500 cc D5W)
Betamethasone 12 mg/IM q 24 x 2 doses

42. Neurology Referral
A> Generalized Tonic-clonic Seizure secondary to right Mesial Temporal Sclerosis
P> No contraindication for use of Tocolytic Drugs or any form of delivery
Refer if with seizure recurrence
May give Diazepam 5mg/IV every 8 hours for active Seizures

43. NST (4th hour)

44. CBC (10/18/10) Ref range Unit Hgb 120-170 g/L 122 RBC 4.0-6.0 X10^12/L
3.66
HCT
0.36
Platelet
X10^9/L
246
WBC
13.10
Differential Count
Neutrophils
0.80
Segmented
Lymphocytes
0.20

45. Urinalysis (10/18/10) Physical Characteristics Microscopic Findings
Color
Yellow
Cells
Transparency
turbid
RBC – 0-2hpf Ph
6.0
Pus cell 1-4hpf
Specific Gravity
1.020
Squamous cell +
Chemical Test
Bacteria ++
Albumin -
Mucus threads ++
Sugar

46. 2nd HD
Isoxsuprine 10mg/tab 1 tab every 8 hours

47. 3rd HD Discharge Medications:
Isoxsuprine 10mg/tab, 1 tab every 8 hours x 2 weeks
Multivitamins 1 cap OD
Ferrous Sulfate, 1 cap OD
Milk 1 glass OD
Special Instructions:
Bed Rest
Avoid Sexual Contact and strenuous activities
Follow-up or Transfer Instructions:
To come back for follow-up on Oct 29, 2010, 8AM at OB-OPD
To come back for follow up at Neurology after 1 week

48. Neurology
Lamotrigine 50 mg/tab ½ tab ODHS

49. Thank You!