High Risk Conference Clerk Emman Carlo R. Evangelista

R. S. 23 y/o, primigravid weeks AOG CC: watery vaginal discharge

HISTORY OF PRESENT ILLNESS hypogastric pain – mild irregular contractions – No consult done or medications taken 11 hrs PTA

HISTORY OF PRESENT ILLNESS Sought consult at our institution S> hypogastric pain – radiating to the lumbosacral area O> Abdomen was globular nontender with NABS, FH 31cm, FHT bpm, UCs irregular, IE showed pink and smooth cervix, 2 cm dilated, (+) BOW A> Pregnancy weeks, cephalic not in labor, fetal hypoplastic ventricles P> advised to go home to come back next day with BPS results 4 hrs PTA

HISTORY OF PRESENT ILLNESS Went back to our institution S> persistence of symptoms (+) clear watery vaginal discharge followed by bloody mucoid vaginal discharge O> Abdomen was globular nontender with NABS, FH 31cm, FHT bpm, Uterine contractions every 2- 3 mins, secs strong External genitalia exam: no gross lesion Speculum exam: cervix violaceous, (+) pooling of blood IE: 5-6cm, 80-90% effaced (-) BOW, ROT st (-)1 A>Pregnancy weeks, cephalic, in labor EROM x 30 mins Fetal hypoplastic ventricle P> Admission 30 mins PTA Admission

REVIEW OF SYSTEMS No weight loss No fever, cough, colds or headache No nausea, vomiting No shortness of breath, dyspnea or chest pain No orthopnea, no easy fatigability No constipation, diarrhea No frequency or difficulty in urination, dysuria or hematuria No easy bruisability or epistaxis No loss of consciousness, seizures, or alteration in mental status

Prenatal History Prenatal check up since 5 weeks AOG at Metropolitan (2 visits). TVS 6/14/2010 – IUP 5 weeks 5 days. Normal ovaries with corpus luteum, right. Prenatal check up at Amisola Hospital since 4 months (5 visits). TVS 6/22/2010 – SLIUP 6 weeks 3 days, mild embryonic bradycardia, minimal subschorionic hemorrhage, small corpus luteum cyst, right.

Congenital scan 11/13/2010 – 4 chamber view of the heart not demonstrated (? Hypoplastic right ventricle) – SLIUP of about weeks, cephalic presentation, normohydramnios, (?) heart problem Fetal 2D echo 11/27/2010 – Hypoplastic right ventricle with probable atretic tricuspid valve, adequate right atrial to left atrial flow Prenatal check up at UST OPD since 36 weeks AOG 5x

January 10, 2011 S(+) Vulvar pruritus OBP 100/70, PR 82, RR 23, T 36.2C Ht 151 cm Wt 163 lbs Pink palpebral conjunctiva, anicteric sclerae Moist buccal mucosa, nonhyperemic PPW, tonsils not enlarged Supple neck, no palpable cervical lymphadenopathies, thyroid not enlarged Symmetrical chest expansion, no retractions, clear and equal breath sounds Globular abdomen, FH 32cm, FHT 139 bpm Ext genitalia: no gross lesions SE: cervix violaceous, smooth, with minimal non foul smelling yellowish mucoid discharge IE: cervix soft long closed, uterus enlarged to 8 months size APregnancy weeks, cephalic, not in labor Trichomoniasis t/c congenital hypoplastic heart URTI prob viral PCBC, urinalysis blood typing, 100g OGTT, HBsAg Fetal 2D echo with BPS Continue multivitamins 1 tab OD, FeSO4 1 tab OD, milk 1 glass OD Metronidazole 500mg BID x 7 days Increase oral fluid intake

2D echo 1/14/2011 – Good contractility of the heart – Difficult fetal echo study

January 17, 2011 SAsymptomatic OBP 100/70, PR 82, RR 23, T 36.2C Ht 151 cm Wt 163 lbs Pink palpebral conjunctiva, anicteric sclerae Moist buccal mucosa, nonhyperemic PPW, tonsils not enlarged Supple neck, no palpable cervical lymphadenopathies, thyroid not enlarged Symmetrical chest expansion, no retractions, clear and equal breath sounds Globular abdomen, FH 31cm, FHT 140 bpm Ext genitalia: no gross lesions SE: cervix pink, smooth, with copious yellowish with whitish curdlike discharge adherent to the vaginal walls IE: cervix soft long closed, uterus enlarged to 8 months size APregnancy weeks, cephalic, not in labor Mixed vaginal infection t/c congenital hypoplastic R ventricle PContinue multivitamins 1 tab OD, FeSO4 1 tab OD, milk 1 glass OD Referral to Pedia Surg Miconazole + Metronidazole vaginal supp 1 supp ODHS for 7 days

January 24, 2011 Sasymptomatic OBP 90/60, PR 92, RR 18, T 36.4C Ht 151 cm Wt lbs Pink palpebral conjunctiva, anicteric sclerae Moist buccal mucosa, nonhyperemic PPW, tonsils not enlarged Supple neck, no palpable cervical lymphadenopathies, thyroid not enlarged Symmetrical chest expansion, no retractions, clear and equal breath sounds Globular abdomen, FH 37cm, FHT 132 bpm, LM1: beech, LM2: FB at left, LM3: cephalic Ext genitalia: no gross lesions SE: cervix violaceous, smooth, with minimal whitish discharge IE: cervix soft long closed, uterus enlarged to AOG APregnancy weeks, cephalic, not in labor Mixed vaginal infection, resolved t/c congenital hypoplastic R ventricle, t/c IUGR PContinue multivitamins 1 tab OD, FeSO4 1 tab OD, milk 1 glass OD Fetal 2D echo BPS with fetal biometry

January 31, 2011 SAsymptomatic OBP 100/70, PR 82, RR 23, T 36.2C Ht 151 cm Wt 163 lbs Pink palpebral conjunctiva, anicteric sclerae Moist buccal mucosa, nonhyperemic post pharyngeal wall, tonsils not enlarged Supple neck, no palpable cervical lymphadenopathies, thyroid not enlarged Symmetrical chest expansion, no retractions, clear and equal breath sounds Globular abdomen, FH 34cm, FHT 132 bpm, LM1: beech, LM2: FB at left, LM3: cephalic Ext genitalia: no gross lesions SE: cervix violaceous, smooth, with minimal non foul smelling yellowish mucoid discharge IE: cervix soft long closed, uterus enlarged to 8 months size APregnancy weeks, cephalic, not in labor t/c fetal hypoplastic R ventricle PContinue multivitamins 1 tab OD, FeSO4 1 tab OD, milk 1 glass OD

February 7, 2011 SAsymptomatic OBP 100/60, PR 98, RR 18, T 36.6C Ht 151 cm Wt 168 lbs Pink palpebral conjunctiva, anicteric sclerae Moist buccal mucosa, nonhyperemic post pharyngeal wall, tonsils not enlarged Supple neck, no palpable cervical lymphadenopathies, thyroid not enlarged Symmetrical chest expansion, no retractions, clear and equal breath sounds Globular abdomen, FH 33cm, FHT 130 bpm Ext genitalia: no gross lesions SE: cervix violaceous, smooth, with minimal non foul smelling yellowish mucoid discharge IE: cervix soft long closed, uterus enlarged to 8 months size APregnancy weeks, cephalic, not in labor Fetal hypoplastic R ventricle PContinue multivitamins 1 tab OD, FeSO4 1 tab OD, milk 1 glass OD

PAST MEDICAL HISTORY (-) previous surgeries (-) asthma (-) blood transfusion (-) DM, HPN, Goiter, Hepatitis B (-) allergies

FAMILY HISTORY (+) DM – paternal grandmother Cancer – liver CA (death of father at 33) (-) HPN, CVA, asthma, tuberculosis

PERSONAL AND SOCIAL HISTORY Non-smoker Non alcoholic beverage drinker No illicit drug use

MENSTRUAL HISTORY Menstrual: 12 years old Interval: every days, Duration: 3-4 days Amount: 4 pads, moderately soaked (+) dysmenorrhea – on days 1-2 relieved by Mefenamic acid 500mg/tab LMP: May 21-23,2010 PMP: April 20-22, 2010

SEXUAL HISTORY First sexual contact at age 22 No postcoital bleeding No dyspareunia No Family Planning Method

PHYSICAL EXAMINATION Conscious, coherent, not in cardiorespiratory distress BP 110/70 PR 86 RR 19 T 37.5C Wt 168 lbs Ht 151 cm Warm moist skin, no active dermatoses Pink palpebral conjunctivae, anicteric sclera (-) tragal tenderness, non-hyperemic EAC, intact TM AU, (-) aural discharge, (-) nasal tenderness, midline nasal septum, (-) nasal discharge moist buccal mucosa, nonhyperemic PPW, (-) oral ulcers, tonsils not enlarged Supple neck, (-) Palpable cervical LN, thyroid not enlarged

PHYSICAL EXAMINATION Adynamic precordium, 5 h LICS MCL, no murmurs Symmetric chest expansion, no retractions, clear breath sounds Globular abdomen, FH 31cm NABS, soft to touch, no tenderness, EFW 5 ½ - 6 lbs LM1: breech LM2:fetal back R LM3 cephalic FHT 130s Uterine contractions every 2-3 mins, secs strong

PHYSICAL EXAMINATION External genitalia exam: no gross lesion Speculum exam: cervix violaceous, (+) pooling of blood IE: 5-6cm, 80-90% effaced (-) BOW, ROT st (-)1 Extremities: (-) cyanosis, (-) edema Pulses full and equal

INITIAL ASSESSMENT Pregnancy weeks, cephalic, in labor EROM x 30 mins Fetal hypoplastic ventricle

INITIAL PLANS LAT CBC with platelet Urinalysis Monitor progress of labor