CC: Watery Vaginal Discharge A.P.T., 36 y/o G1P0 (0000) 40-41 weeks AOG CC: Watery Vaginal Discharge

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, 30-40 seconds duration, mild-moderate. Non-stress test: reactive LMP: feb 28, 2010. 4 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

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, 2010. 4 weeks age of gestation No medications taken (+) hypogastric pain radiating to the lumbosacral area (-) watery/bloody discharge (+) good fetal movement

LMP: January 18 – 21, 2010 PMP: December 18 – 21, 2010 AOG by LMP: 41-42 weeks AOG by ultrasound: 40-41 weeks

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

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

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

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

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: 28-30 days Duration: 3-4 days Amount: 4 pads per day, moderately soaked Symptoms: (-) dysmenorrhea

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

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

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: 110/60 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

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 0.37-0.54 0.36 Platelet 150-450 X10^9/L 321 WBC 4.5-10.0 8.5 Differential Count Neutrophils 0.50-0.70 Segmented 0.56 Lymphocytes 0.20-0.40 0.39 Monocytes 0.00-0.07 0.03 Eosinophils 0.01-0.04 0.02

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

ULTRASOUND PHOTOS

(-) danger signs of pregnancy 6/1/10; 19-20 weeks AOG S> (+) weakness, easy fatigability and occasional dizziness(-) no other symptoms noted (-) danger signs of pregnancy O> BP: 90/60 PR: 93 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 19-20 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

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: 100/60 PR: 94 T: 37 °C Wt: 150.5 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

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

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: 110/70 PR: 98 T: 36.3 °C Wt: 150.8 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

Fetal Biometry (8/10/10) Single live intrauterine pregnancy of about 29-30 weeks AOG, cephalic presentation Male BPS 8/8 SEFW 1342 grams AFI: 22.92 cm Placenta: posterior, grade 1 in maturity Fetal Biometry: BPD: 7.29 cm AC: 24.86 cm FL: 5.49 cm FAC: 24.86 cm

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

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: 100/60 PR: 86 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 10-11 am Saturdays Retrieve OR tech and record of management of breast CA TCB after 2 weeks Edema resolved?

09/06/10 33 weeks AOG S> Asymptomatic (-) danger signs (+) good fetal movement O> BP: 110/80 PR: 92 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

09/27/10 36 weeks AOG S> Asymptomatic (-) danger signs (+) good fetal movement O> BP: 110/70 PR: 89 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

Fetal Biometry (10/06/10) Single live intrauterine pregnancy of about 35-36 weeks AOG, cephalic presentation, BPS 8/8, SEFW 3005 grams; Polyhydramnios Male AFI: 28.55 cm Placenta: posterior, grade III Fetal Biometry: BPD: 8.75 cm HC: 31.93 cm FL: 6.69 cm FAC: 34 cm

10/06/10 37-38 weeks AOG S> Asymptomatic (-) danger signs, (+) irregular painless uterine contractions, (+) good fetal movement O> BP: 110/70 PR: 89 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

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: 100/70 PR: 80 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 32-33 weeks, cephalic, not in labor; (?) Leaking bag of water; Vulvar varicosities; Seizure disorder; Grandmultipara P> For BPS with AFI now Follow up with results

BPS (10/11/10) Single live intrauterine pregnancy of about 31-32 weeks in cephalic presentation BPS 8/8 SEFW 1639 grams AFI: 15.02 cm Placenta anterior, grade 1

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 ++

ULTRASOUND PHOTOS

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

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

Physical Examination on Admission Conscious, coherent, not in cardiorespiratory distress BP 120/80 PR 84 RR 16 T 36.5 °C Weight: 146 lbs Height: 157.5 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

Globular abdomen, FH 30 cm LM1 - breech LM2 - FBR LM3 – cephalic FHT 150 bpm Uterine contractions every 7 minutes 40-50 seconds, mild to moderate IE: cervix 2-3 cm dilated, 50% effaced, (+) BOW, cephalic, floating Extremities: (-) edema, (-) cyanosis; pulses full and equal

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

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

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

LAT (10/18/10)

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

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

NST (4th hour)

CBC (10/18/10) Ref range Unit Hgb 120-170 g/L 122 RBC 4.0-6.0 X10^12/L 3.66 HCT 0.37-0.54 0.36 Platelet 150-450 X10^9/L 246 WBC 4.5-10.0 13.10 Differential Count Neutrophils 0.50-0.70 0.80 Segmented Lymphocytes 0.20-0.40 0.20

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

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

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

Neurology Lamotrigine 50 mg/tab ½ tab ODHS

Thank You!