1. PERTINENT DATA
HISTORY OF PRESENT
ILLNESS
PHYSICAL
EXAMINATION
DIAGNOSTICS PREOPERATIVE DIAGNOSIS
KAV 21/M
G3P2 (2002)
Prenatal check-up:
Concepcion HC 1x
Chief complaint:
Labor pains
Past Medical History:
Unremarkable
Family History:
Unremarkable
Personal and Social History:
Unremarkable
OB History:
G1- G2: NSD, live,Term,
Health center, Midwife
assisted
G3 - Present Pregnancy
Gynecologic History:
Unremarkable
Few hours prior to
admission, patient had
labor pains increasing in
intensity associated with
watery vaginal discharge.
She was brought to
Concepcion District
Hospital but was
eventually transferred in
our institution for further
evaluation and
management.
Weight: 153 kg
Height: 58 cm
BMI: 24.8 kg/m2
Normal
BP 100/70
HR 98
RR 21
T 36.8
O2 sat: 99% at room air
Fundic Height: 23 cm
FHT: 130s by doppler, RLQ
EFW by cupping method:
1000-1200 grams
Internal Examination:
Cervix fully dilated, fully
effaced, cephalic St +2, (-)
BOW, clear
Urinalysis
Pus 0-2
RBC 10-15
Protein negative
Glucose negative
RDT: Nonreactive
HBsAg: Nonreactive
No ultrasound
G3P2 (2002) Pregnancy uterine 25 weeks Age of
gestation, Cephalic in Preterm labor
Plan: Expectant Management
Condition explained
Final Diagnosis
G3P3 (2103) Pregnancy Uterine delivered preterm,
cephalic, to a live baby boy, AS 7,8 BW 1.1kg, Ballard
Score 28 weeks, AGA via Normal Sontaneous Delivery
*Baby is admitted at NICU
Awake, fair activity, with alar flaring, grunting and
retractions
A: Prematurity 28 weeks by Ballards Score, Respiratory
Distress Syndrome
P: for NIPPV
Start on ampicillin, gentamicin
Standby intubation
*Expired after 1.5 hours of life
Pediatric Final diagnosis:
Respiratory Distress Syndrome Severe, Prematurity 28
weeks by Ballards Score
CBC
Hgb 130
Hct 0.393
WBC 10.85
Plt 283,000
