LEORAG, KIMBERLY ANN A.

September 2, 2020

HISTORY, PHYSICAL EXAMINATION, AND FORMULATION REPORT

Date of interview: September 7, 2020

Time of interview: 4:15 PM
Informant: Patient
% Reliability: 97%

GENERAL DATA: A.V., 36 years old, female, G3P1(1011), married, teacher, Filipino, Roman
Catholic, a resident of Mandaue City, Cebu sought consult for the first time at the ER of UC
Medical Center on September 7, 2020 at 4:15 PM due to vaginal bleeding.

CHIEF COMPLAINT: Vaginal bleeding

PAST MEDICAL HISTORY:

FAMILY HISTORY:
Patient’s father died at age of 59 due to complications of hypertension and stroke. Patient’s
mother, aged 60 years old, is alive and apparantly well with no known comorbidities. Patient is
an only child. Heredofamilial disease includes hypertension on the paternal side. No family history
of twinning and congenital anomalies.

PERSONAL AND SOCIAL HISTORY:

Patient worked as an elementary teacher. She lives in a residential house in Mandaue City, along
with her husband, her child, and their helper. Before opening of virtual classes had started, she
spent her time on baking. Her exercise comprise of a 15-minute walks daily. She sleeps well for
8 hours. Her diet consists of meat, chicken, fish and vegetable. She usually consumes 2 liters of
water per day. She is non-alcoholic beverage drinker, non-smoker, and denies use of illicit drugs.
No known food and drug allergies.

OBSTETRICS AND GYNECOLOGIC HISTORY

Menstrual History:
Menarche was at age 14 with a reguar menstrual cycle of 28 days. Usual menstrual bleeding lasts
for 4 days, consuming on average 4 pads per day. Patient experience mild dysmenorrhea every
menstrual bleeding with pain score of 2-3/10. No skipping of period, no spotting or bleeding in
between menses. LMP is December 21, 2019. PMP is on third week of November 2019.

Contraceptive History:
Patient had previously taken oral contraception consisting of Cyproterone + Ethinylestradiol
(Diane-35) for 1 year, first taken after the delivery of her 2nd pregnancy. No side effects were noted
upon and after taking this medication. She stopped using this oral contraception after 1 year as
they have decided to have another baby.

Sexual History:
Coitarche was at age 26. She since only had one sexual partner which is her husband. She claims
to be sexually active with good sexual satisfaction. No postcoital bleeding and/or discharge, no
dyspareunia, no sexual dysfunction.

Obstetrics History:
Patient is G3P1(1011). Her first pregnancy was spontaneously aborted at approximately 8 weeks
AOG, with no need for dilation and curettage.
Her second pregnancy was delivered at term via normal spontaneous vaginal delivery on July 24,
2018 at Perpetual Succour Hospital with labor lasting for 8 hours and no complications during and
after delivery. Baby is a girl weighing approximately 3 kg (6 lb and 8 ounces) at birth.
Current pregnancy is currently at 37 and 2/7 weeks AOG by LMP. Estimated date of confinement
is September 28, 2020.
Aside from her first pregnancy aborting spontaneously, there is no other abnormal pregnancies.

Prenatal History:
Patient maintains a balanced healthy diet throughout her pregnancy with no known chronic illness.
Patient’s first prenatal consult for this current pregnancy was at approximately 12 weeks AOG by
LMP. She underwent routine CBC, ultrasound, and urinalysis and was diagnosed with UTI treated
with cefuroxime 500 mg BID for 10 days. Patient takes folic acid supplements 1 tablet per day
and calcium supplements 2 tablets per day, both started during her 1st prenatal visit with good
compliance. She switched to iron supplements during her second trimester, one tablet per day
with good compliance, and mineral supplements, dose unrecalled. She was given flu vaccine at
20 weeks AOG and TDAP at approx. 36 weeks AOG. No fever, no prior bleeding, no prior
exposure to radiation.

HISTORY OF PRESENT ILLNESS:

Two weeks prior to arrival at the ER, patient felt intermittent pain with a pain score of 2-3/10 with
sudden “firmness” on the hypogastric area. No watery or bloddy discharge were noted along with
onset of pain. No fever, no dizziness, no headache, no vomiting.
Three hours prior to arrival at the ER, patient experienced the same pain intermittent pain with a
pain score of 2-3/10 with sudden “firmness” on the hypogastric area.

2 hours and 30 minutes prior to arrival at the ER, patient experienced excessive bleeding
estimated to be around 500 mL of bright red in color.

2 hours prior to arrival at the ER, bleeding was noted to have reduced to a spotting. Patient no
longer felt any pain but the constriction and feeling of “firmness” in the hypogastric area still
persisted.
PHYSICAL EXAMINATION:
General Survey: Examined an awake, active, coherent, cooperative patient, not in respiratory
distress, with the following vital signs:
BP: 100/60 mmHg (supine, right arm)
HR: 100 bpm
RR: 22 cpm
Temp: 36.5 C (axillary)
O2 Saturation: 98%
Height: 157 cm
Prepregnancy Weight: 50 kg
Pregnancy Weight: 68 kg
BMI: 27.4 kg/m2

Skin: Skin is soft and warm to touch with good turgor. No rashes, no active lesions, no jaundice,
no discoloration. Nails are not cyanotic with no clubbing.

HEENT:
Head: Head is normocephalic with no lumps. Hair is black, evenly distributed throughout
the head.

Eyes: Palpebral conjunctivae of both eyes are pinkish. Sclera of both eyes are anicteric
with transparent cornea.

Ears: No discharges, or swelling.

Nose & Paranasal Sinuses: Nares are patent with no discharges and no alar flaring.
Nasal mucosa is pink with septum at midline. There is no sinus tenderness.

Mouth and Throat: Lips are pink and moist. Buccal mucosa is pink with no lesions. There
is no tonsillopharyngeal congestion.

Neck: Neck is supple with no cervical lymphadenopathies. No masses.

Breast and Axilla: s fair, symmetrical, no rashes, no dimpling, no flattening, no tenderness, no

palpable nodules, nipples everted, no discharges.

Chest and Lungs: There is equal chest expansion with no deformities, no intercostal retractions,
and no abnormal respiratory movement of lower intercostal spaces. Tactile fremitus is equal on
both lung fields. Both lung fields are resonant upon auscultation with vesicular breath sounds over
both lung fields with no adventitious breath sounds. No evidence of rales, crackles, or wheezes.
No bronchophony, no egophony, no whispered pectoriloquy. Diaphragm descents 4 cm
bilaterally.

Cardiovascular: The JVP is 3 cm above the sternal angle with the head of bed elevated to 30 0.
Carotid upstrokes are brisk, without bruits. PMI is tapping, 1 cm lateral to the midclavicular line in
the 5th intercostal space, 2 cm in diameter. S1 and S2 is crisp and distinct with regular rhythm and
rate. At the base, S2 is louder than S1 with physiologic split of A2 > P2. At the apex, S1 is louder
than S2. There are no murmurs or extra sounds.

Abdomen: Gravid, (+), linea nigra, (+) striae gravidarum, (-) Ceasarean/surgical scars, fundal
height at 32 cm, LM1 head, nodular non-ballotable mass, LM2 firm structure (fetal back) at
maternal left side and fetal extremities on maternal right side, LM3 hard, round, nonmovable, LM4
cephalic prominence flet on maternal right side, FHR 155 bpm, no uterine contractions palpated.

GUT: no lesions, no internal examination done, speculum exam done with positive pooling of
blood. Minimal active bleeding from cervical os. Cervix is close.

Female External Genitalia: No inguinal adenopathy. External genitalia without erythema,

lesions, or masses.

Peripheral Vascular: No cyanosis, no pitting edema, no limitation of movements, with strong

peripheral pulses.

Extremities: Good range of motion in the hands, wrists, elbows, shoulders, spine, hips, knees,
and ankles. No evidence of swelling or deformity.

Neurologic Exam: unremarkable.