History#3

Historian: Singh Kushwaha Rabindra K.

Date of Interview: 02/20/2016

I. Identifying Data

E.E, a 45 year old female born on August 22, 1970, unmarried, Filipino, house wife, currently residing
Lawak East Alcala, Pangasinan. First time consultation in Ramos-Tablizo, Maternity clinic and was
reffered to Sto. Nino. General hospital on February 14, 2016 at 5.30 PM. Second time consultation in
Ramos-Tablizo, Maternity Clinic on February 20, 2016 at 8.00 AM.

Informant: Patient

Reliability: 90%

II. Chief Complaint

Vaginal spotting

III. History of present illness

1 day PTA:

Patient E.E experienced abdominal pain while sleeping, radiating from the umbilical area, with
a pain scale of 5/10. Associated symptoms includes dizziness and headache. She also noted clumps of
non- foul smelling vaginal blood. She had no fever. Patient took her medicine that includes duvadilan
(isoxsuprine hydrochloride) and mosvit gold (multivitamins and minerals) to relieve the pain. There
was no noted change with her condition.

1 Hr. PTA:

Patient was still having abdominal pain and vaginal spotting. Pain scale was 8/10. She again
took her medicines to relieve the pain and took a rest, but there was no change with her condition.
This prompted the patient to consult in Ramos-Tablizo, Maternity Clinic. She was eventually referred
to Sto. Nino General Hospital, Bayambag, Pangasinan.

IV. Past Medical History:

Childhood illness: Chicken pox, measles and mumps

Allergy: Asthma

Immunization: claimed completed, no adult immunization

No history of hypertension, diabetes, kidney or gastrointestinal disease.

 V. Family History

Father:

75 years old and hypertensive.

Mother:

No known illnesses at 75 years old.

Patient`s brother died of cardiac arrest at 36 years old.

Maternal side has history of hypertension.

Hypertension and breast cancer is known to have with her paternal side.

VI. Personal and Social History:

Patient is a high school graduate in Hagonoy Institute, Rizal, and OFW since she was 28 years old.
She is not married, but has live-in partner. She has 19 year old daughter from a former partner.

E.E started smoking cigarettes since she was 28 years old, consuming 1 pack per day but stooped
5 years ago. She also drinks hard liquor, which she recently stopped after learning of her pregnancy.
Her diet includes mostly of fish and vegetables. Drinking water is tap. She jogs once a week as form of
exercise. She lives in a bunglow with her partner

VII. OB GYNE History:

A. Menstrual History:

LMP: November 7, 2015

Menarche 13 y/o, 3 days duration, consuming 4 pads/day fully soaked (moderate flow), regular 28-
30 day cycle.

B. OB History:

OB SCORE: G2 P1, (1 0 1 1)

G1- October 13, 1996; full term baby, NSD by a midwife in Bulacan.

G2- Miscarriage (7-8 wks AOG).

C. Gynecologic History:

No history of Pap smear was done. She uses withdrawal birth control method.

D. Sexual History:

Coitarche: unrecalled

VII. Review of Systems

General Symptomatology: (-) fever, (-) weakness, (-) weight loss

Integumentary: (-) rashes, (-) pruritus, (-) straie gravidarum, (-) linea nigra
 Head: (-) lesions, (-) swelling

Eyes: (-) tearing, (-) redness, (-) blurring of vision

Ears: (-) discharge

Nose: (-) sneezing, (-) colds, (-) epistaxis, (-) discharges

Mouth and throat: (-) gum bleeding, (-) swelling, (-) dysphagia

Neck: (-) mass, (-) lesions

Respiratory: (-) cough, (-) phlegm, (-) dyspnea

Cardiac: (-) palpitations, (-) edema, (-) dyspnea, (-) orthopnea, (-) easy fatigability

GIT: (-) diarrhea, (-) vomiting (-) hypogastric pain, (-) epigastric pain

GUT: (-) urinary frequency, (-) hematuria, (-) dysuria, (+) vaginal spotting with blood clots

Musculoskeletal: (-) stiffness, (-) joint pains, (-) lumbosacral pain, (-) bipedal edema

Hematologic: (-) bleeding tendencies, (-) varicosities, (-) bruising, (-) petechiae, (-) hematoma

Endocrine: (-) polyphagia, (-) polyuria, (-) heat or cold intolerance, (-) profuse sweating

Nervous: (-) convulsions, (-) tremors, (-) fainting

VIII. Physical Examination

General survey: conscious, coherent, ambulatory, not in cardiopulmonary distress

VS: BP: 120/90 mmHg PR: 84 bpm RR: 16 cpm T: 35.2 C

Skin: (-) pallor, (-) chloasma, (-) acne, (-) varicosities, warm to touch, good skin turgor

HEENT:

Head: Hair is blonde with equal distribution and normocephalic.

Eyes: No noted lesions, masses or tenderness.

Ears: No mass, lesions or tenderness noted. Both ears are patent.

Nose: Nasal septum is at midline, no nasal discharge, lesion, tenderness or masses.

Mouth: Uvula is at the midline, Pinkish and moist buccal mucosa. No lesions, tenderness or
mass noted.
 Neck: Neck is symmetrical with no tenderness or mass noted upon palpation.

Chest and Lungs Examination:

INSPECTION: Skin is brown in color, no lesions and with good muscle development. The thorax is
elliptical, symmetrical and with no bony deformities. No Intercostal retractions, no bulging, no
widening or narrowing of ICS, no lagging of the chest during respiration. Patient has regular rhythm.

PALPATION: No tenderness, no mass noted. Chest expansion is symmetrical on both anterior and
posterior chest.

PERCUSSION: Lung fields are resonant on both anterior and posterior chest.

AUSCULTATION: Vesicular breath sounds noted on peripheral lung fields. No adventitious breath
sounds noted.

Cardiovascular Examination:

INSPECTION: No neck vein engorgement noted. No bulging or depression of the precordium.

AUSCULTATION: No murmur or bruit appreciated

PALPATION: No thrills, no lifts and no heaves appreciated.

Abdominal Examination:

INSPECTION: abdomen is flat.

AUSCULTATION: was not able to perform.

PALPATION: not performed

PERCUSSION: not performed

Extremities Examination: Has full range of motion on both upper and lower extremities.

Neurological Examination: The patient is conscious, coherent, and alert. Recent, remote and
immediate memory is intact.

Test for cranial nerves, and other test were not performed.

Initial Impression

1. Vaginal spotting with blood clots and abdominal pain suggest missed abortion.

Laboratory Investigation:

Serial HCGs: plateau or drops

Sonographic Findings:

Absence of any growth of the gestational sac or fetal pole over a 5-day period of observation.
 Gestational sac larger than 12 mm mean diameter (around 5 weeks 5 days) without visual
evidence of a yolk sac.
Absence of a visible fetal heartbeat when the crown-rump length (CRL) is greater than 5 mm.
Yolk sac larger than 6 mm diameter
Yolk sac that is abnormally shaped or echogenic (sono dense rather than the normal sono
lucent).
No fetal cardiac activity, especially when it was previously seen.

Differential Diagnosis

RULE IN RULE OUT

Septic abortion (+) Vaginal spotting (-) pyrexia
(+) lower abdominal pain (-) purulent vaginal discharge
Normal pulse rate
Inevitable (+) Vaginal spotting (-) product of conception at internal os of cervix
miscarriage/Threatened (+) lower abdominal pain *Internal examination needed to rule out (os
miscarriage closed threatened and open in inevitable).
*Ultrasound needed to rule out
Ectopic Pregnancy (+) Vaginal spotting
(+) lower abdominal pain *Ultrasound needed to rule out

Management:
Uterus is less than 12 weeks:

(i) Expectant managementmany women expel the conceptus spontaneously

(ii) Medical management: Prostaglandin E1 (Misoprostol) 800 mg vaginally in the posterior fornix is
given and repeated after 24 hours if needed. Expulsion usually occurs within 48 hours

(iii) Suction evacuation or dilatation and evacuation is done either as a definitive treatment or it can
be done when the medical method fails. The risk of damage to the uterine walls and brisk hemorrhage
during the operation should be kept in mind.

Uterus more than 12 weeks:

Induction is done by the following methods:

Prostaglandins are more effective than oxytocin in such cases. The methods used are:

a. Prostaglandin E1 analogue (misoprostol) 200 g tablet is inserted into the posterior vaginal fornix
every 4 hours for a maximum of 5 such.
b. Oxytocin1020 units of oxytocin in 500 mL of normal saline at 30 drops per minute is started. If
fails, escalating dose of oxytocin to the maximum of 200 mlU/min, may be used with monitoring.

c. Many patients need surgical evacuation following medical treatment. Following medical treatment,
ultrasonography should be done to document empty uterine cavity. Otherwise evacuation of the
retained products of conception (ERPC) should be done.

d. Dilatation and evacuation is done once the cervix becomes soft with use of PGE1. Otherwise
cervical canal is dilated using the mechanical dilators or by laminaria tent. Evacuation of the uterine
cavity is done thereafter slowly.