ob hx may 6 ectopic

Our Lady of Lourdes HospitalDepartment of Obstetrics and Gynecology

May 7, 2014

Identifying Data

Patient is Daisy Jane A. Legaspi 36 year old G2P1 (1001), married, pharmacist, Filipino, currently residing in Sta. Mesa, who was admitted for the 2nd time at OLLH on May 6, 2014.

Chief Complaint

Vaginal Spotting

History of Present Pregnancy

LMP: March 23, 2014

EDC: December 28, 2014

AOG: 6 weeks and 2 days

History of Present Problem

13 days prior to admission, patient started to notice vaginal spotting and uses 2-3 pads per day with blood stained of 3 finger breadths for 5 days. She did not consult and no medications were taken. Patient was apparently well until 1 day prior to admission her vaginal spotting returned and uses 2-3 pads per day with blood stained of 5 fingerbreadths. She seek consult at OLLH emergency department and was given with Isoxilan tab 3 times a day and was sent home.

Few hours prior to admission her vaginal spotting persisted. She was sent to OLLH emergency department and was assessed by Dra. Managuelod. She underwent transvaginal ultrasound which revealed ectopic pregnancy hence she was subsequently admitted for possible salpingectomy.

Antenatal History

Patient had monthly prenatal check up with Dra. Managuelod.

Past Medical History

Patient denies of having hypertension, diabetes, bronchial asthma, COPD, PTB, allergy, cancer, coronary disease, heart failure, arthritis, skin disease, blood dyscrasia, thyroid disease, kidney disease and neuro-psychiatric disorders.

PGI AMER HUSSIEN P. SAMPORNA

2012 she was diagnose to have acute gastritis and was given with Omeprazole 40 mg/tab once a day.

Family History

Her mother was diagnosed to have diabetes. She denies other heredo familial diseases like hypertension, asthma, kidney disease, allergy, cancer and live diseases.

Personal and Social History

She is a non-smoker, non-alcoholic beverage drinker and denies use of illicit drugs.

Menstrual History

Menarche at the age of 13, regular menstruation, 3-5 days , uses 2-3 pads per day moderately soaked and she has no dysmenorrhea.

Sexual History

She had her first sexual intercourse at the age of 18. She and her husband do not use any contraceptive method.

OB History

G2P1(1001)

G1: (2010) Pregnancy Uterine Full Term via Normal Spontaneous Vaginal Delivery at OLLH, with no feto-maternal complications

G2: (2014) Present Pregnancy

Review of Systems:

General: no weight loss or easy fatigability

CNS: No headache or dizziness

Respiratory: no difficulty of breathing, any colds or cough

Cardiovascular: No chest pain and no palpitations

Gastrointestinal: No diarrhea, nausea, vomiting, or constipation

Genitourinary: No dysuria, polyuria, hematuria or urinary urgency, no discharge

Extremities: No weakness or numbness

Psychiatric: No mood changes, depression or suicide attempts


Physical Examination:

General Survey: Conscious, coherent and not in cardiorespiratory distress.

Vital Signs : BP 120/90 mmHg,

HR: 89 bpm,

RR: 18cpm

Temp: 36.5 ‘C.

HEENT:

Head: normocephalic, no scars, no contusion no lesions

Eyes: anicteric sclerae, pinkish palpebral conjunctiva, pupils briskly reactive to light, 2-3 mm

Nose: no discharge, nasal septum midline, no nasal flaring

Mouth: pink oral mucousa, no exudates no lesions

Neck: no lymphadenopathy, no mass, no swelling, thyroid not enlarge

Throat: no tonsillar swelling

Thorax and Lungs: symmetrical, no retraction, no use of accessory muscle, Equal chest expansion, Clear breath sounds

Cardiovascular: adynamic precordium , regular rhythm and rate , distinct heart sound, no murmur

Abdomen: soft , flat, direct tenderness on right lower quadrant, normoactive bowel sounds

Extremities: no deformities, no cyanosis , <2 sec capillary refill time, no edema, full pulses

Neurologic: Intact cranial nerves, good muscle tone, no motor and sensory deficits

IE: cervix is closed, no cervical motion tenderness, with blood per examining finger, with tenderness on left adnexa

ADMITTING DIAGNOSIS:

Ectopic Pregnancy 6 2/7 weeks AOG


G2P1 (1001)

PLAN:

Admit patient

Monitor vital signs

Do transvaginal ultrasound

Medical Management:

Methothrexate for rapid absorption of placental tissues

Surgical Management:

Request for CBC, 12L ECG, Protime, Blood typing, serum electrolytes, BUN and Crea, HBsAg

Partial Salpingectomy, Salpingostomy, Salpingotomy


ob hx may 6 ectopic

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